Mortality by age, gene and gender in carriers of pathogenic mismatch repair gene variants receiving surveillance for early cancer diagnosis and treatment: a report from the prospective Lynch syndrome database

Background

The Prospective Lynch Syndrome Database (PLSD) collates information on carriers of pathogenic or likely pathogenic MMR variants (path_MMR) who are receiving medical follow-up, including colonoscopy surveillance, which aims to the achieve early diagnosis and treatment of cancers. Here we use the most recent PLSD cohort that is larger and has wider geographical representation than previous versions, allowing us to present mortality as an outcome, and median ages at cancer diagnoses for the first time.

Methods

The PLSD is a prospective observational study without a control group that was designed in 2012 and updated up to October 2022. Data for 8500 carriers of path_MMR variants from 25 countries were included, providing 71,713 years of follow up. Cumulative cancer incidences at 65 years of age were combined with 10-year crude survival following cancer, to derive estimates of mortality up to 75 years of age by organ, gene, and gender.

Findings

Gynaecological cancers were more frequent than colorectal cancers in path_MSH2, path_MSH6 and path_PMS2 carriers [cumulative incidence: 53.3%, 49.6% and 23.3% at 75 years, respectively]. Endometrial, colon and ovarian cancer had low mortality [8%, 13% and 15%, respectively] and prostate cancers were frequent in male path_MSH2 carriers [cumulative incidence: 39.7% at 75 years]. Pancreatic, brain, biliary tract and ureter and kidney and urinary bladder cancers were associated with high mortality [83%, 66%, 58%, 27%, and 29%, respectively]. Among path_MMR carriers undergoing colonoscopy surveillance, particularly path_MSH2 carriers, more deaths followed non-colorectal Lynch syndrome cancers than colorectal cancers.

Interpretation

In path_MMR carriers undergoing colonoscopy surveillance, non-colorectal Lynch syndrome cancers were associated with more deaths than were colorectal cancers. Reducing deaths from non-colorectal cancers presents a key challenge in contemporary medical care in Lynch syndrome.

Funding

We acknowledge funding from the Norwegian Cancer Society, contract 194751-2017.

Monoclonal Gammopathy in Chronic Lymphocytic Leukemia: A Case Report and Review of its Literature

The presence of monoclonal gammopathies in B-cell malignancies occurs frequently. Monoclonal proteins are present in a significant number of patients with chronic lymphocytic leukemia (CLL), which is a disorder of antigen-stimulated mature B-cells. The recognition of monoclonal proteins or light chains in the serum and/or urine is increased in the majority of CLL patients with the use of highly sensitive laboratory methods such as serum immunofixation studies. A different autoimmune phenomenon may explain the presence of some of these monoclonal proteins. Some reports indicate that the finding of monoclonal proteins has a negative impact on patients' survival. However, there is no clear evidence to suggest the prognostic significance of monoclonal proteins in patients with CLL. Although the presence of monoclonal proteins in CLL occurs usually at an incidence of 60%–80%, there are very few cases reported in literature. We report a case of CLL diagnosed in 2009 who developed disease progression along with the presence of immunoglobulin kappa monoclonal gammopathy. Although the presence of monoclonal gammopathy might be due to the use of highly sensitive methods, this can be due to autoimmune phenomenon or development from the same or different clone of B-cells.

Bevacizumab based chemotherapy is a promising option in metastatic gallbladder adenocarcinoma

Gallbladder cancer (GBC) is one of the most frequently observed cancers in India that is usually diagnosed at an advanced stage. Although surgery remains the only curative option, the majority of GBCs are unresectable. Palliative chemotherapy with gemcitabine and cisplatin is the recommended treatment in such cases. The current study reports a case of a 47-year-old female who exhibited GBC that had metastasized to the liver and peritoneum. She was administered palliative chemotherapy with gemcitabine and cisplatin, but due to disease progression the regimen was changed and an aggressive treatment initiated with gemcitabine and oxaliplatin with additional biosimilar bevacizumab (modified Gemox-B regimen). The patient completed six chemotherapy cycles with partial response and received bevacizumab (7.5 mg/kg 3-weekly) based maintenance treatment for an additional 6 cycles, after which she demonstrated disease progression, thus having a progression free survival of ~11 months. The patient is currently receiving palliative chemotherapy with capecitabine.

Current Treatment Options for Human Epidermal Growth Factor Receptor 2-Directed Therapy in Metastatic Breast Cancer: An Indian Perspective

Human epidermal growth factor receptor 2 (HER2)-positive is an aggressive subtype of breast cancer and has historically been associated with poor outcomes. The availability of various anti-HER2 therapies, including trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine (TDM-1), has remarkably improved the clinical outcomes in patients with HER2-positive metastatic breast cancer (mBC). However, there is a need to optimize treatment within this population, given the wide variability in clinical presentation. Additionally, geographical and socio-economic considerations too need to be taken into account. To clarify and collate evidence pertaining to HER2-positive metastatic breast cancer, a panel of medical and clinical oncologists from across India developed representative clinical scenarios commonly encountered in clinical practice in the country. This was followed by two meetings wherein each clinical scenario was discussed in detail and relevant evidence appraised. The result of this process is presented in this manuscript as evidence followed by therapeutic recommendations of this panel for management of HER2-positive mBC in the Indian population.

Minimally Differentiated Acute Myeloid Leukemia: A Morphologic, Cytochemical and Ultrastructural Study

Seven of 368 cases of acute myeloid leukemia (AML) could not be subclassified by routine morphologic, cytochemical and immunologic analyses during the period January 1989 to December 1990. Further investigations including ultrastructural examination, anti-myeloperoxidase and myeloid specific antigen analysis were carried out in all these patients and they were classified as AML-MO, as per the FAB criteria. Morphologically these blasts resembled ALL-L2/AML-M1. Cytochemlcally they were negative for Sudan black, myeloperoxidase, periodic acid-Schiff, and non-specific esterase. On initial immunophenotypic analysis, they could not be classified Into B, T or myeloid lineages. Further investigations revealed CD13 and CD33 positivity in 4 of 6 patients. Anti-myeloperoxidase was positive in 6 of 6 patients and ultrastructural examination revealed myeloperoxidase-positive blasts in 6 of 7 cases. Cytogenetic analysis done in one patient revealed 60 % abnormal metaphases. Six of 7 cases were treated with aggressive chemotherapy. One patient achieved complete remission but relapsed after 6 months, whereas others were resistant to treatment. Hence we conclude that an aggressive investigative and therapeutic approach is required to identify and treat AML-MO.

Studies on Granulocyte Functions in Patients with Chronic Myeloid Leukemia

Granulcoyte functions, viz. endocytosis, NADPH oxidase activity and iodination by leukocytes, were studied in granulocytes isolated from 17 chronic myeloid leukemia (CIVIL) patients at initial diagnosis (stage I), from 10 patients in relapse (stage II), and 10 patients in acute blastic crisis (stage III). The mean phagocytic index of granulocytes from CML patients was similar to the normal value. NADPH activity decreased as the disease progressed. Thus, the amount of formazan produced was lower in granulocytes from patients in stage II (P < 0.05) and stage III (P < 0.01) than that produced by normal granulocytes. H2O2-Myeloperoxidase-dependent iodination was found to be significantly reduced in granulocytes from all stages of the disease compared to that of normal, stage I (P < 0.01), stage II (P < 0.05) and stage III (P < 0.01). It thus seems that granulocyte function becomes less efficient as the disease progresses towards acute blastic crisis. Immature cells from the same patients carried out these functions at a more reduced level than did their mature counterparts.

T-Cell Chronic Lymphocytic Leukemia

A case of T-cell chronic lymphocytic leukemia (T-CLL) is reported. The surface receptor for sheep erythrocytes and acid phosphatase staining confirmed the diagnosis of T-CLL. This report provides evidence that T-CLL, a rare variant of CLL, is an aggressive disease with relative resistance to therapy and short survival.

Advanced therapeutic options and importance of rebiopsy in epidermal growth factor receptor-tyrosine kinase inhibitor-progressed nonsmall cell lung carcinoma patients: An expert opinion

Advanced nonsmall cell lung cancer (NSCLC) treatment is primarily based on platinum-based chemotherapy. Although epidermal growth factor receptor (EGFR) targeting has shifted the treatment paradigm toward personalized tyrosine kinase inhibitors (TKIs), resistance develops inevitably and EGFR T790M is the most common acquired resistance mechanism. Rebiopsy of resistant NSCLC cases can provide additional information on the underlying resistant mechanisms and therefore can help clinicians in taking better management decisions. An expert panel meeting of renowned cancer oncologists was held to discuss the management of advanced-stage NSCLC. The present paper is based on the recommendations made by the expert panel and is supported by an exhaustive literature search. It was suggested that identification of driver mutation leads to better treatment decisions. TKIs have proven to be better treatment option in EGFR-positive patients as compared to chemotherapy. Third-generation TKIs (osimertinib) promise to bring optimal and improved care for NSCLC cases failing first-line TKI treatment.

Indian Council of Medical Research Consensus Document for the Management of Non-Hodgkin's Lymphoma (High Grade)

This consensus document is based on the guidelines related to the management of Non Hodgkin's Lymphoma (High grade) in the Indian population as proposed by the core expert committee. Accurate diagnosis in hematolymphoid neoplasm requires a combination of detailed history,clinical examination, and various investigations including routine laboratory tests, good quality histology section (of tumor and also bone marrow aspirate/biopsy), immunostaining, cytogenetic and molecular studies and radiology investigations. The staging system used for adult high grade lymphomas is based on the Ann Arbor system and includes various parameters like clinical, haematology, biochemistry, serology and radiology. Response should be evaluated with radiological evaluation after 3-4 cycles and at the end of treatment based on criteria including and excluding PET. Treatment of high grade lymphomas is based on histologic subtype, extent of disease, and age of the patient. Autologous stem cell transplantation after high dose chemotherapy is effective in the treatment of relapsed NHL. Newer RT techniques like 3 dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) can significantly reduce radiation doses to surrounding normal tissues in lymphoma patients. Patients should be followed up every 3 to 4 months for the first 2 years, followed by 6 monthly for the next 3 years and then annually.

Kodameae ohmeri - An Emerging Yeast: Two Cases and Literature Review

Kodameae ohmeri is an emerging pathogen in various types of infections. Most infections are seen in patients with compromised immunity like cancer patients. Few cases of neonatal infections due to K. ohmeri have been reported earlier in premature neonates with fatal outcomes. We report two cases of fungemia; the first case was a patient with hematological malignancy, who complained of fever spikes and grew K. ohmeri in blood despite prophylactic voriconazole therapy. The second case was in a mature neonate, who developed respiratory distress and features of sepsis two days after birth, multiple blood cultures were positive for K. ohmeri. Both the patients responded well to Amphotericin B. Repeat blood cultures were sterile and patients were discharged. K. ohmeri is an unusual and emerging fungal pathogen of late an increasing number of cases of fungemia, funguria, endocarditis, peritonitis and wound infections due to the same are being reported. Some occur in immunocompromised patients and some inapparently immunocompetent patients, neonates with an inclination for preterm babies. We report two case of fungemia, one with lymphoma and the second in a neonate.

Saree cancer in Indian woman treated successfully with multimodality management

Saree is a common, traditional garment of Indian women, wrapped around the waist is tightened by a thick cord and with one end draped over the shoulder. Tight knot in the same place, sweat, soiling and continuous use can cause pigmentation, scaling of the waist and even transform to malignancy. We present here a case of saree cancer successfully managed with multimodality therapy. A 50-year-old woman was referred to our hospital (India) for itching and non-healing ulcerative lesion on waistline. She was wearing saree continuously for 34 years with knot at the same place. Magnetic resonance images suggested ulcerative growth with lymph node metastasis. She then underwent wide local excision; histopathological examination confirmed it was a squamous cell carcinoma. She therefore received concomitant chemotherapy and radiotherapy. She is now (2 years after the completion of treatment) in remission state. Awareness of saree cancer among Indian is important to avoid malignant lesions at waistline. Multimodality management with surgery, chemotherapy and radiotherapy is ideal mean for good outcome.

Report of chronic myelogenous leukemia in chronic phase from, Asian Institute of Oncology, Mumbai, 2002-2010

Chronic myeloid leukemia (CML) has paradigm shift in its treatment modality after the discovery of targeted therapy Imatinib. At our centre we collected data of 100 consecutive patients over a period of 8 years. The interesting finding in our study was difference in the survival of patients presenting in early chronic phase (81%) versus late chronic phase (16%). Also the patients with primary resistance did poorly compared to the patients who developed secondary resistance to Imatinib.

A multicenter phase II randomized study of Cremophor-free polymeric nanoparticle formulation of paclitaxel in women with locally advanced and/or metastatic breast cancer after failure of anthracycline

AIMS

Paclitaxel is extensively used in the treatment of advanced carcinomas of the breast, ovary and non-small cell lung cancer. In clinical use it is formulated in the non-ionic surfactant polyethoxylated castor oil (Cremophor) and dehydrated alcohol to enhance drug solubility. Cremophor adds to toxic effects of paclitaxel by producing or contributing to the well-described hypersensitivity reactions that commonly occur during its infusion, affecting a large number of patients. This randomized trial was conducted to evaluate efficacy and safety of novel nanoparticle-based paclitaxel in the treatment of patients with advanced breast cancer.

METHOD

Patients were randomized to receive either nanoparticle paclitaxel (NP) 300 mg/m(2) , (NP300) or NP220 mg/m(2) or Cremophor paclitaxel 175 mg/m(2) (CP 175). NP was administered as a 1-h infusion without premedication and CP as a 3-h infusion with premedication every 3 weeks.

RESULTS

In total, 194 patients who had been administered at least one dose were included for safety analysis and 170 patients who completed at least two cycles of therapy were analyzed for efficacy. NP showed an overall response rate (complete response + partial response) of 40% in the NP220 and NP300 arms as compared to 31% in the CP arm. The incidence of neutropenia (all grades) was lowest in the NP220 arm (39.4%) compared to the NP300 (55%) and CP arm (50%).

CONCLUSION

NP is well tolerated and can be safely administered without any premedication in comparison to conventional paclitaxel, which requires the use of premedication before administration. NP demonstrates promising efficacy with a favorable safety profile.

An elderly woman with triple primary metachronous malignancy: A case report and review of literature

INTRODUCTION

Prevalence of multiple primary malignancies is slowly increasing due to prolonged survival of cancer patients with advances in diagnostic and therapeutic modalities. The reasons may be environmental modifications, genetic predisposition or therapy induced. We describe a case of a 64-year-old woman with three different metachronous primary malignancies managed at our center since 4 years.

PRESENTATION OF CASE

First primary diagnosed in our patient was adenocarcinoma of small intestine which is a rare gastrointestinal malignancy. For this she underwent surgical resection followed by chemotherapy. After 21 months she developed infiltrating duct carcinoma of breast which was managed with modified radical mastectomy and chemotherapy. Again after latent period of 10 months patient had papillary adenocarcinoma of ovary for which she was administered chemotherapy. During follow up tumor was found to be chemoresistant and again she underwent cytoreductive surgery followed by chemotherapy.

DISCUSSION

In present case patient did not have significant risk factors for development of carcinoma of small intestine, breast and ovary. Our patient underwent surgical excision three times and received total 16 chemotherapy cycles of different regimens during management of all three primary malignancies. Development of second and higher order primary malignancy after successful management of previous one should be always kept in mind.

CONCLUSION

Awareness, suspicion of multiple primary malignancy and aggressive diagnostic work up plays crucial role in their detection at earlier stage for better outcome. In addition choice of appropriate chemotherapeutic agents and their regimens remains the cornerstone while managing the patients with multiple primary malignancies.

RhoA: a therapeutic target for chronic myeloid leukemia

Background

Chronic Myeloid Leukemia (CML) is a malignant pluripotent stem cells disorder of myeloid cells. In CML patients, polymorphonuclear leukocytes (PMNL) the terminally differentiated cells of myeloid series exhibit defects in several actin dependent functions such as adhesion, motility, chemotaxis, agglutination, phagocytosis and microbicidal activities. A definite and global abnormality was observed in stimulation of actin polymerization in CML PMNL. Signalling molecules ras and rhoGTPases regulate spatial and temporal polymerization of actin and thus, a broad range of physiological processes. Therefore, status of these GTPases as well as actin was studied in resting and fMLP stimulated normal and CML PMNL.

Methods

To study expression of GTPases and actin, Western blotting and flow cytometry analysis were done, while spatial expression and colocalization of these proteins were studied by using laser confocal microscopy. To study effect of inhibitors on cell proliferation CCK-8 assay was done. Significance of differences in expression of proteins within the samples and between normal and CML was tested by using Wilcoxon signed rank test and Mann-Whitney test, respectively. Bivariate and partial correlation analyses were done to study relationship between all the parameters.

Results

In CML PMNL, actin expression and its architecture were altered and stimulation of actin polymerization was absent. Differences were also observed in expression, organization or stimulation of all the three GTPases in normal and CML PMNL. In normal PMNL, ras was the critical GTPase regulating expression of rhoGTPases and actin and actin polymerization. But in CML PMNL, rhoA took a central place. In accordance with these, treatment with rho/ROCK pathway inhibitors resulted in specific growth inhibition of CML cell lines.

Conclusions

RhoA has emerged as the key molecule responsible for functional defects in CML PMNL and therefore can be used as a therapeutic target in CML.

Randomized, Double-Blind, Placebo-Controlled Phase II Study of Single-Agent Oral Talactoferrin in Patients With Locally Advanced or Metastatic Non–Small-Cell Lung Cancer That Progressed After Chemotherapy

Purpose

To investigate the activity and safety of oral talactoferrin (TLF) in patients with stages IIIB to IV non–small-cell lung cancer (NSCLC) for whom one or two prior lines of systemic anticancer therapy had failed.

Patients and Methods

Patients (n = 100) were randomly assigned to receive either oral TLF (1.5 g in 15 mL phosphate-based buffer) or placebo (15 mL phosphate-based buffer) twice per day in addition to supportive care. Oral TLF or placebo was administered for a maximum of three 14-week cycles with dosing for 12 consecutive weeks followed by 2 weeks off. The primary objective was overall survival (OS) in the intent-to-treat (ITT) patient population. Secondary objectives included progression-free survival (PFS), disease control rate (DCR), and safety.

Results

TLF was associated with improvement in OS in the ITT patient population, meeting the protocol-specified level of significance of a one-tailed P = .05. Compared with the placebo group, median OS increased by 65% in the TLF group (3.7 to 6.1 months; hazard ratio, 0.68; 90% CI, 0.47 to 0.98; P = .04 with one-tailed log-rank test). Supportive trends were also observed for PFS and DCR. TLF was well tolerated and, generally, there were fewer adverse events (AEs) and grade ≥ 3 AEs reported in the TLF arm. AEs were consistent with those expected in late-stage NSCLC.

Conclusion

TLF demonstrated an apparent improvement in OS in patients with stages IIIB to IV NSCLC for whom one or two prior lines of systemic anticancer therapy had failed and was well tolerated. These results should be confirmed in a global phase III trial.

Granulocyte colony-stimulating factor (filgrastim) in chemotherapy-induced febrile neutropenia

Background:

The use of granulocyte colony-stimulating factors to treat patients with chemotherapy-induced neutropenia is well accepted. To assess whether administration of filgrastim along with standard empiric antibiotic therapy is beneficial for patients with chemotherapy-induced febrile neutropenia (FN), we conducted an open, non-randomized clinical trial.

Materials and Methods:

This was a prospective, open, Phase IV clinical trial in patients receiving chemotherapy for histologically confirmed cancer, with an oral temperature of >38.2°C and absolute neutrophil count (ANC) of <500/mm ³. Filgrastim was administered subcutaneously in a dose of 5 mcg/kg/day, 24 hours after administration of cytotoxic therapy, for up to two weeks or until the ANC reached 10,000 cells/mm ³. The parameters of assessment included duration of neutropenia, fever, hospitalization and antibiotic usage.

Results:

All 24 evaluable patients recovered from neutropenia, fever and FN in a median duration of two days. This result is similar to that reported in earlier studies with filgrastim. Despite the acceleration in recovery from neutropenia and fever, it also reduced the duration of hospital stay and usage of intravenous (IV) antibiotic. Only two adverse events were reported, which were of mild nature.

Conclusion:

Filgrastim, when used in patients with chemotherapy-induced neutropenia, exhibited efficacy in accelerating the recovery from neutropenia and fever comparable to that reported with filgrastim in literature. The data from this study suggest that filgrastim is effective in the treatment of chemotherapy-induced neutropenia and is well tolerated by Indian patients.

Targeting mTOR pathway: A new concept in cancer therapy

This article highlights the current knowledge of mTOR biology and provides new insights into the role of mTOR in different cancers. An active mTOR coordinates a response in cell growth directly through its effects on cell cycle regulators and indirectly by sustaining nutrient supply into the cell through the production of nutrient transporters and also through the promotion of angiogenesis. A primary way that mTOR exerts its regulatory effects on cell proliferation is by controlling the production of cyclin D1. mTOR increases the translation of hypoxia-inducible factor 1 (HIF-1)/HIF-2. The HIF transcription factors drive the expression of hypoxic stress response genes, including angiogenic growth factors such as vascular endothelial growth factor (VEGF), platelet-derived growth factor β (PDGF-β), and transforming growth factor a (TGF-α). mTOR also increases the surface expression of nutrient transporters proteins. An increase in these proteins results in greater uptake of amino acids and other nutrients by the cell leading to adequate nutrient support to abnormal cell growth and survival. There is also emerging evidence that mTOR activation may play a role in promoting cell survival through the activation of antiapoptotic proteins that contribute to tumor progression. Given that the mTOR pathway is deregulated in a number of cancers, it is anticipated that mTOR inhibitors will have broad therapeutic application across many tumor types. Until now, no treatment demonstrated Phase III evidence after disease progression on an initial VEGF-targeted therapy in advanced renal cell carcinoma. Everolimus is the first and only therapy with Phase III evidence after failure of VEGF-targeted therapy. Everolimus is a once-daily, oral inhibitor of mTOR (mammalian target of rapamycin) indicated for the treatment of advanced renal cell carcinoma in patients, whose disease has progressed on or after treatment with VEGF-targeted therapy.

Post-Therapy Profile of Serum Total Cholesterol, Retinol and Zinc in Pediatric Acute Lymphoblastic Leukemia and Non-Hodgkin's Lymphoma

OBJECTIVE

To assess serum albumin, total cholesterol, retinol, zinc and hemoglobin in children who had completed treatment for acute lymphoblastic leukemia (ALL) and Non-Hodgkin's lymphoma (NHL).

METHODS

The above parameters were analyzed in 105 ALL and NHL and 108 age and sex-matched controls. Serum albumin, serum cholesterol and hemoglobin were estimated by colorimetric methods. Serum retinol was estimated by HPLC and serum zinc was estimated by atomic emission spectrophotometer (ICP-AES). Comparisons were made to stage of treatment (maintenance 6 with post-therapy), type of treatment (chemotherapy and radiation with only chemotherapy) and type of malignancy (ALL with NHL).

RESULTS

Only serum albumin in patients included at Maintenance(6) was significantly higher (t = 2.31, p = 0.05) than post-therapy patients. No significant difference in serum values was observed by type of treatment. Only total cholesterol was significantly higher in NHL patients than in ALL patients (t = 1.954, p = 0.05). Patients had comparable serum levels to that of controls. However, in patients and controls more than 75% children had deficient serum retinol levels, (< than 0.6989 micromol/l, or 20 microg/dl). Further, 75% patients and 54.7% controls had serum retinol levels less than 0.3439 micromol/l or 10 microg/dl.

CONCLUSION

The results of the present study indicate that cancer and its treatment did not have any long-lasting effect on serum albumin, total cholesterol, retinol, zinc and hemoglobin. Majority of subjects had low serum retinol suggestive of depleted liver reserves. The deficient serum retinol levels (< than 0.6989 micromol/l, or 20 microg/dl) in at least 75% of the patients and controls probably reflect poor dietary intake. A higher percentage of patients with low serum retinol levels may also be attributed to the possibility of urinary losses of retinol that occur during episodes of infection while on immunosuppressive anti-cancer drug therapy.

Altered Ca2+ homeostasis in polymorphonuclear leukocytes from chronic myeloid leukaemia patients

Background

In polymorphonuclear leukocytes (PMNL), mobilization of calcium ions is one of the early events triggered by binding of chemoattractant to its receptors. Besides chemotaxis, a variety of other functional responses are dependent on calcium ion mobilization. PMNL from chronic myeloid leukaemia (CML) patients that were morphologically indistinguishable from normal PMNL were found to be defective in various functions stimulated by a chemoattractant – fMLP. To study the mechanism underlying defective functions in CML PMNL, we studied calcium mobilization in CML PMNL in response to two different classical chemoattractants, fMLP and C5a.

Results

Release of calcium estimated by flow cytometry and spectrofluorimetry using fluo-3 as an indicator showed that the [Ca²⁺]_i levels were lower in CML PMNL as compared to those in normal PMNL. But, both normal and CML PMNL showed maximum [Ca²⁺]_i in response to fMLP and C5a at 10 sec and 30 sec, respectively. Spectrofluorimetric analysis of the total calcium release in chemoattractant treated PMNL indicated more and faster efflux of [Ca²⁺]_i in CML PMNL as compared to normal PMNL.

Conclusion

Fine-tuning of Ca²⁺ homeostasis was altered in CML PMNL. The altered Ca²⁺ homeostasis may contribute to the defective functions of CML PMNL.

Myelomatous pleural effusion

Serous effusions in multiple myeloma are uncommon but a myelomatous pleural effusion occurring in these patients is extremely rare. Here we report a rare case of a 38 years lady who was diagnosed to have multiple myeloma and subsequently developed pleural effusion. The myelomatous nature of the effusion was first diagnosed on cytology and subsequently confirmed by a pleural biopsy. The pleural effusion showed an initial response to chemotherapy but subsequently recurred.

Primary non-Hodgkin's lymphoma of the spleen presenting as space occupying lesion: a case report and review of literature

Primary splenic lymphoma (PSL) is rare with a reported incidence of less than 1%. Diffuse large cell pathology has been reported in 22-23% of the cases and is felt to have poor outcome. This study reports a 50 year old male who presented with fever and weakness. He was found to have a mass lesion in the spleen documented by CT scan. A splenectomy was performed which showed non-Hodgkin's lymphoma. Immunohistological studies showed a positivity for CD20 and CD30.

Safe and efficacious use of procedural sedation and analgesia by non-anesthesiologists in a pediatric hematology-oncology unit

BACKGROUND

Children often require relief of pain and anxiety while undergoing diagnostic and therapeutic procedures. Procedural sedation and analgesia (PSA) is the safe and effective control of pain, anxiety and motion so as to allow a necessary procedure to be performed and to provide an appropriate degree of memory loss or decreased awareness.

OBJECTIVE

To prospectively describe procedural sedation and analgesia as performed in the pediatric oncology unit and to report the success of sedation and the incidence of complications.

METHODS

IV Midazolam and IV Ketamine were used for PSA in pediatric oncology patients undergoing painful procedures.

RESULTS

Between June 2004 and December 2004, 55 diagnostic and therapeutic procedures were performed using PSA in 16 children. There were 9 boys and 7 girls with a median age of 11 years. Twelve patients had hematolymphoid malignancies and 4 patients had solid tumors. The indication for PSA were bone marrow aspiration and or biopsy in 7 patients, therapeutic lumbar puncture in 43 patients, bone marrow aspiration and lumbar puncture in 4 patients and skin biopsy in 1 patient. All 55 procedures were successfully completed. Adverse events occurred in 15 (27%) episodes and included transient drop in oxygen saturation, vomiting, dizziness and disinhibition with crying spells. Average time to arousable state and full recovery was 22 minutes and 31 minutes respectively. None of the patients complained of post procedure pain nor recalled the procedure at the follow up visit.

CONCLUSION

Procedural sedation and analgesia using midazolam and ketamine is a safe and efficient method of limiting anxiety and procedure related pain and can be successfully administered by non-anaesthesiologists. The complication rate is low and can be easily managed.

Impaired cell motility in chronic myeloid leukemic granulocytes related to altered cytoskeletal pattern

The bactericidal activity of polymorphonuclear leucocyte (PMNL) against infection stimulates cytoskeletal changes accompanied with alteration in adhesion and locomotion. Microfilaments, the motile apparatus is known to regulate these changes by polymerization of monomeric G-actin to fibrous F-actin. PMNL from chronic myeloid leukemia (CML) patients have been reported to be defective in locomotion in response to synthetic peptide, n-formyl-methionyl-leucyl-phenylalanine (fMLP) but the mechanism leading to defective locomotion and their spatial reorganization remains unclear. Therefore, in order to study the cause of defective motility of PMNL from CML patients the spatial distribution and reorganization of microfilaments and microtubules in response to fMLP have been examined by transmission electron (TEM) and scanning electron microscopy (SEM). Under SEM, the PMNL-CML surface appeared smoother with reduced ruffling resulting in rounding off cells with lesser polarized morphology. Unstimulated PMNL from normal as well as CML subjects showed shorter and fewer microtubules and evenly distributed microfilaments as compared to fMLP stimulated PMNL. It is proposed that the cause of defective locomotion was due to reduced surface activity as a consequence of altered cytoskeletal configuration. This phenomenon seems to be related to impaired functional appendages and as a whole led to the defective cell motility and hence reduced chemotaxis in PMNL from CML patients.

Antibodies against 9-O-acetylated sialic acids in childhood acute lymphoblastic leukemia: a two-year study with 186 samples following protocol MCP 943

Initial studies have revealed an enhanced surface expression of 9-O-acetylated sialoglycoconjugates (9-OAcSGs) on lymphoblasts concomitant with high titers of antibodies (anti-9-OAcSGs) in childhood acute lymphoblastic leukemia (ALL). This study was undertaken in 186 coded samples from 69 ALL patients to evaluate if antibodies against these sialoglycans could monitor response to the treatment. An ELISA was developed using bovine submaxillary mucin (BSM) containing high % of 9-O-acetylated sialic acids (9-OAcSA) as the capture antigen, to investigate serum levels of anti 9-OAcSGs in a single-center series of pediatric, clinically-diagnosed and immunophenotypically confirmed ALL patients, as compared to 130 healthy controls. At presentation, a 3.8-fold increase in anti-9-OAcSGs levels was detected in 63/69 ALL patients (mean +/- SEM was 102.8 +/- 6.3 microg/ml) as compared to normal controls (27.17 +/- 0.76 microg/ml), assay sensitivity being 91.3%. On an individual basis (n = 25) in patients who were longitudinally monitored for two years, a significant decline in their mean +/- SEM of OD405 was observed from 0.85 +/- 0.06 to 0.28 +/- 0.03. Additionally, a dot-blot was developed to evaluate the proportion of immune-complexed 9-OAcSGs in these patients employing achatinin-H, a 9-OAcSA-binding lectin. Our data indicate that these economically viable ELISA-based approaches allow for reliable, sensitive and rapid diagnosis of ALL. We contend that these disease-specific antibodies could be considered as potential markers both for the initial diagnosis of ALL and possibly for longitudinal monitoring of the disease.

T- cell prolymphocytic leukemia - a rare case

T- cell Prolymhocytic leukemia (T-PLL) is a rare mature post-thymic T-cell malignancy that is usually reported in the elderly and follows an aggressive course. A 68 year old male presented with a history of weakness and weight loss of two months duration. Clinical examination revealed pallor, enlarged cervical and axillary lymph nodes and splenomegaly. He also had a maculo- papular skin rash. There was marked leucocytosis, anemia and thrombocytopenia (WBC 445 x 103 sub/ml, Hb 8.5 gm/dl, Platelet 25 x 103 sub/microl) with 60% prolymphocytes in the peripheral blood. Bone marrow was hypercellular with an excess of prolymphocytes. Flow cytometric analysis of the bone marrow showed positivity for CD2, CD3, CD4, CD5 and CD 7. T- PLL is a rare T cell disorder with characteristic clinical and laboratory features. Currently, no optimal treatment exists although there has been some success with 2'- deoxycoformycin or Campath-1H.

First-line gemcitabine versus epirubicin in postmenopausal women aged 60 or older with metastatic breast cancer: a multicenter, randomized, phase III study

BACKGROUND

This randomized, phase III study compared the efficacy and safety of first-line gemcitabine versus epirubicin in the treatment of postmenopausal women with metastatic breast cancer (MBC).

PATIENTS AND METHODS

Patients aged > or = 60 years (median 68 years) with clinically measurable MBC received either gemcitabine 1200 mg/m(2) or epirubicin 35 mg/m(2) on days 1, 8, and 15 of a 28-day cycle.

RESULTS

Of 410 patients entered, 397 (198 gemcitabine and 199 epirubicin) were randomized and qualified for the time to progressive disease (TTP) and survival analyses. Total cycles administered in 185 gemcitabine and 192 epirubicin patients, respectively, were 699 (mean 3.5, range 0-12) and 917 (mean 4.6, range 0-10). Epirubicin demonstrated statistically significant superiority in TTP (6.1 and 3.4 months, P=0.0001), overall survival (19.1 and 11.8 months, P=0.0004), and independently assessed response rate (40.3% and 16.4% in 186 and 183 evaluable patients, P <0.001). For gemcitabine (n=190) and epirubicin (n=192), respectively, common WHO grade 3/4 toxicities were neutropenia (25.3% and 17.9%) and leukopenia (14.3% and 19.3%). Of the 28 on-study deaths (17 gemcitabine, 11 epirubicin), three were considered possibly or probably related to treatment (gemcitabine).

CONCLUSIONS

Postmenopausal women > or =60 years of age with MBC tolerate chemotherapy well. In this study, epirubicin was superior to gemcitabine in the treatment of MBC in women age > or =60, confirming that anthracyclines remain important drugs for first-line treatment of MBC.

Cumulative risk and trends in prostate cancer incidence in Mumbai, India

BACKGROUND

Information relating to cancer incidence trends in a community forms the scientific basis for the planning and organization of prevention, diagnosis and treatment of cancer. We here estimated the cumulative risk and trends in incidence of prostate cancer in Mumbai, India, using data collected by the Bombay Population-based Cancer Registry from the year 1986 to 2000.

METHODS

During the 15 year period, a total of 2864 prostate cancer cases (4.7% of all male cancers and 2.4% of all cancers) were registered by the Bombay Population-based Cancer Registry. For evaluation of the trend, we applied a linear regression model based on the logarithm of the observed incidence rates. The annual percentage changes were also computed for the evaluation. Cumulative incidence rates percentages were calculated by adding up the age specific incidence rates at single ages and then expressed as a percentage.

RESULTS

Analysis of the trends in age-adjusted incidence rates of prostate cancer during the period 1986 to 2000 showed no statistically significant increase or decrease and the rates proved stable across the various age groups (00-49, 50-69 and 70+) also. The probability estimates indicated that one out of every 59 men will contract a prostate cancer at some time in his whole life and 99% of the chance is after he reaches the age of 50.

CONCLUSION

The stability in age adjusted-incidence rates indicates that there are no changes in the etiological factors for prostate cancer in Mumbai, India. These findings may be of general interest because changes in diagnostic practices are confounded in the time trends of prostate cancer change in many western countries preventing inferences on the changes in risk.

Activation of HHV-6 in lymphoproliferative disorders: a polymerase chain reaction-based study

HHV-6 is a latent herpes virus persisting throughout the adult life of the infected host in an integrated form and is often activated in immunocompromised situations. Detection of HHV-6 DNA in the plasma of an individual indicates the presence of active viral replication in the host. Because lymphomas are known to be associated frequently with host immunosupression, we studied activation of HHV-6 in 98 patients diagnosed with Hodgkin's disease (HD) or non-Hodgkin's lymphoma (NHL). HHV-6 activation was documented in 34% of cases of non-Hodgkin's lymphoma and 39% of those of Hodgkin's disease; however, no correlation of activation status with pathological types of Hodgkin's disease and between copy numbers in peripheral blood mononuclear cell DNA and the corresponding plasma DNA was noticeable.

Oral cancers in Mumbai, India: a fifteen years perspective with respect to incidence trend and cumulative risk

OBJECTIVE

We estimated the time trends in the incidence and the risk of developing an oral cancer in Mumbai, Indian population using the data collected by the Bombay Population Based Cancer Registry during the 15 year period from 1986 to 2000.

METHODS

A total of 9,670 oral cancers (8.2% of all neoplasms) were registered, of which 6577 were in males and 3093 in females (10.7% and 5.4% of the respective totals for the two genders). For evaluation of the trend, we applied a linear regression model based on the logarithm of the observed incidence rates. The annual percentage changes were also computed for the incidence rates to evaluate the time trend.

RESULTS

In males, a statistically significant decreasing trend in the overall age-adjusted incidence rates were observed during the period 1986 to 2000, with an yearly decrease of 1.70%. This decrease was significant for men above the age of 40, but for young adult men below the age of 40, there was no significant decrease, the level being stable. In females, the overall decreasing trend in the age-adjusted incidence rates of oral cancers was not significant, but in the age group 40-59, a significant decline was observed. The probability estimates indicated that one out of every 57 men and one out of every 95 women will contract any oral cancer at some time in their whole life and 97% of the chance is after he or she completes the age of 40.

CONCLUSION

The observed decreasing trend in oral cancers in Indian men may be attributed to a decrease in the usage of pan and tobacco. The high prevalence of the usage of smokeless tobacco among young adult men and women may explain the stable trend in oral cancer incidence in this group. These findings help to strengthen the association between tobacco use and oral cancer risk.

Imatinib in gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of gastrointestinal tract. The tumors express the cell surface transmembrane receptor KIT that has a tyrosine kinase activity and is a protein product of KIT protoeoncogene. These tumors occur in the whole of Gastrointestinal tract. Treatment includes surgical resection for localized tumors. For metastatic disease treatment options include systemic chemotherapy, radiation therapy, with a response rate of less than 10%. Presently Imatinib; a tyrosine kinase inhibitor has shown promising result with response rates upto 59-69% in phase II results in metastatic setting; and ongoing phase II & phase III trials in adjuvant setting will help to establish its role as an adjuvant to surgery. We have treated eleven patients of metastatic GIST with Imatinib and we hereby present these cases.

Decreasing trend in the incidence of stomach cancer in Mumbai, India, during 1988 to 1999

The time trend in incidence of stomach cancer in males and females in Mumbai, India during 1988 to 1999 was estimated using data collected by the Bombay Population-based Cancer Registry. During the 12-year period, a total of 3657 stomach cancer cases (3.9% of all cancers) were registered by the Bombay Population-based Cancer Registry of which 2467 (5.1% of all male cancers) were in males and 1184 (2.6% of all female cancers) in females. For evaluation of the trend, we applied a linear regression model based on the logarithm of the observed incidence rates. The annual percentage changes were also computed for the incidence rates for evaluating the time trend. A statistically significant decreasing trend in the overall age-adjusted incidence rates of stomach cancer was observed during the period 1988 to 1999, with an yearly decrease of 4.44% in males and 2.56% in females. This decrease was most striking in males in the age groups 40-59 and 60+, and in females only in the age group 40-59. The probability estimates indicated that one out of every 92 men and one out of every 187 women will contract a stomach cancer at some time in their whole life and 95% of the chance is after his or her 40th birthday. The decreasing trend in the age-adjusted incidence rates of stomach cancer in both the sexes indicates that there is a critical change in the etiology of this cancer. The findings may provide clues relating to various life-style and environmental changes impacting on stomach cancer incidence.

Hypercalcemia induced by parathyroid hormone-related peptide after treatment of squamous cell carcinoma of oral cavity

Squamous cell carcinoma of the head and neck is a rare cause of humoral hypercalcemia of malignancy. This paraneoplastic syndrome is usually one of the presenting symptoms of the disease. We report a case of squamous cell carcinoma of the oral cavity that presumably elaborated parathyroid hormone-related peptide (PTH-rP) and caused hypercalcemia only after radiotherapy and chemotherapy.

Use of a reduced-intensity conditioning regimen for allogeneic transplantation in patients with chronic myeloid leukemia

Reduced-intensity conditioning that harnesses the potential of a graft-versus-tumor (GVT) effect has been proposed as an alternative to conventional myeloablative allogeneic stem cell transplantation. The primary aim is engraftment and this can be achieved with minimal immunosuppression. In this report, we describe the use of such regimens for CML in 17 patients who received human leukocyte antigen (HLA)-matched sibling allografts. Conditioning was with fludarabine, antithymocyte globulin (ATG) and busulfan for the first 11 patients, whereas fludarabine, busulfan and TBI were used for the remaining six patients. Engraftment was prompt in most of the cases. Complications and need for supportive therapy in the immediate post-transplant period were reduced drastically. Only two patients (both in the TBI group) died within the first 100 days. Acute graft-versus-host disease (GVHD) grade II-IV was seen in seven patients. Complications occurred later on. Chronic GVHD was observed in 11/17 patients. Lung infection and GVHD were the major killers. In surviving patients, after a median follow-up of 30 months (range 37-21 months), 6/17 (35.3%) are alive. Five are disease free and one patient is still in relapse even after a second donor lymphocyte infusion. Total treatment time and cost were more than with conventional transplants. We conclude that reduced-intensity transplantation still requires further refinement.

Benign multilocular cystic nephroma

This article reports a case of cystic nephroma to bring awareness about the benign nature of this condition. The patient presented with a painless abdominal mass. Computed tomography showed a homogeneous, multicystic tumor of the superolateral portion of the left kidney with thin septa without solid parts. Histology confirmed the diagnosis of cystic nephroma.

Retinoblastoma: An Epidemiological Appraisal with Reference to a Population in Mumbai, India

Reliable data on incidence and mortalityfor childhood cancers are available from only a few areas in the developing countries. Neoplasia in children is rare as compared with adult cancer. In Europe, North America and Australia, retinoblastomas account for 2-4 percent of the total and the relative frequency is similar in Asia. In contrast, in African countries retinoblastomas account for 10 to 15% of cancers in children. The data collected at Bombay Cancer Registry for the latest 13 years, 1986-1998, were used for the present study. Analyses were carried out on retinoblastomas by sex, age, religion and laterality, based on differences in rates and proportions. In Mumbai, during the 13-year period in question, there were only 211 cases of malignant tumors of the eyes. Of these, 147 were retinoblastomas, 84 in males and 63 in females, with crude incidence rates per million population of 4.0 and 3.1, respectively. The corresponding age adjusted incidence rates per million population were 4.2 and 3.3. The crude values were found to be higher in Muslims as compared to Hindus and other religious groups, in both sexes. Out of the total retinoblastomas, 105 were localized, 24 demonstrated regional spread and 16 had metastasized or were very advanced. Some 23 patients had bilateral disease. In a total of 60 patients, retinoblastomas developed on the right side and in 58 in the left eye. The highest annual age standardized incidence rates for retinoblastomas, in excess of 7 per million population have been observed in the Fortaleza area of Brazil, Nigeria (Ibadan) and Uganda-Kampala. Retinoblastomas have the lowest median age of all childhood malignancies, approximately 15 months. The male to female ratio generally fluctuates around unity but our data indicated a higher proportion in males. Ethnic differences in the frequencies of unilateral and bilateral retinoblastomas are apparent. There is little evidence that any significant change in the incidence of retinoblastoma over time has occurred in any part of the world. Knudson proposed a 2-mutation hypothesis to explain the occurrence of retinoblastoma in both hereditary and sporadic forms with differing frequencies of bilaterality, and this model has become a paradigm for considering the role of genetic factors in the etiology of cancer in general.

An Assessment of Cancer Incidence Patterns in Parsi and Non Parsi Populations, Greater Mumbai

The Mumbai Cancer Registry has been in operation since 1964 and reliable morbidity and mortality data on cancer have been obtained for the first time in India, from a precisely outlined population. An attempt has been made to examine the differences noticed in the site-specific cancer risk, between two groups of people living in this area-the Parsi and non Parsi population of Mumbai. For this study, data has been utilized, collected by Mumbai Cancer Registry for the latest five years. For comparison between Parsi and non Parsi populations, crude and age-adjusted rates have been used. The overall age-adjusted rates for the Parsi's were found to be lower than those for the non Parsi populations and more noticeably their site-specific risks seem to differ radically from the non Parsi pattern. Cancers of the buccal cavity, pharynx, larynx, oesophagus and cervix uteri which are frequently seen in the non Parsi population, are less commonly observed in the Parsi community. On the other hand the Parsi rates are higher at site such as the female breast, endometrium, lymphomas and leukaemias. The observed site-specific contrast are believed to be due to differences present in the habits, customs and economic status of the two groups.

Leukemia in infants

OBJECTIVE

Acute Leukemia is rare in infants. It is characterized by non-specific symptomatology requiring a high index of suspicion on the part of a pediatrician for referral and diagnosis. It has peculiar biological features, unresponsiveness to treatment and poor prognosis.

METHODS

Eighteen infants with acute leukemia were seen during 1994 to 2001 and were analyzed on the basis of clinical and laboratory data. There were 13 cases of Acute Lymphoblastic Leukemia (ALL), 4 cases of Acute Myeloid Leukemia (AML) and one case remained unclassifiable, as the surface markers could not be done. Morphologically 9/13 cases of ALL were of FAB L1 type and remaining of L2 subtype, and 2/4 cases of AML were of FAB M1 type and remaining of M2 subtype.

RESULT

Clinical data was available completely only in 11 cases. Hyperleucocytosis was present in 4 cases, organomegaly in 8 cases and lympadenopathy in 5 cases. One patient presented with a chloroma in the retrorbital region although there was no parenchymal involvement of the brain. Immunophenotyping could be done in 13 cases, where 7 cases were diagnosed as CALLA positive-ALL (HLADR+, CD19+, CD10+), 2 cases as Early Pre-B ALL (HLADR+, CD19+, CD10 negative), one as T ALL (cCD3+, CD2+, CD7+) and 3 cases as AML (CD13+, CD33+, HLADR+). None of our patients received treatment.

Expression of P53 and bcl-2 proteins in T-cell lymphoblastic lymphoma: prognostic implications

In patients (pts) with non-Hodgkin's lymphoma (NHL) under 25 years, treatment with MCP-842 protocol, a short duration intense protocol, yields worse survival in pts with lymphoblastic lymphoma (LL) compared to other high grade lymphomas. In order to identify both favourable and unfavourable subgroups in pts with T-cell LL (T-LL) with respect to relapse free survival following treatment with MCP-842 protocol, we analysed the expression of p53 and bcl-2 proteins in 22 pts with T-LL treated at the Tata Memorial Hospital, Mumbai by immunohistochemistry. p53 protein overexpression was noted in 59% cases and bcl-2 overexpression was noted in 29.4% cases. p53 expression correlated with a higher rate of relapse (p = 0.03; RR 7.9). The 5-year relapse free survival (RFS) was better in p53 negative patients compared to positive patients (70 vs 38%) (log-rank sigma = 0.04). In conclusion, in this study, overexpression of p53 protein was common in patients with T-LL. T-LL pts negative for p53 are likely to benefit from the short intense protocol--MCL-842. Bcl-2 protein overexpression was not a prognostic factor in these patients.

Protein kinase C isoforms in normal and leukemic neutrophils: altered levels in leukemic neutrophils and changes during myeloid maturation in chronic myeloid leukemia

Protein kinase C (PKC) is reported to play a role in maturation of the myeloid cell and functions of the mature neutrophil. The neutrophils in chronic myeloid leukemia (CML) exhibit defects in several functions. As a step towards understanding the role of PKC in the defects in function of the leukemic cells, this study investigates the expression of PKC isoforms, their subcellular distribution, levels and kinase activity in the normal and leukemic neutrophils. It also investigates changes in representative PKC isoforms during myeloid maturation. This study confirms the presence of PKC alpha, beta and delta and shows, for the first time, the presence of non conventional PKC isoform theta, atypical PKC isoform lambda/iota and PKC isoform mu in normal human neutrophils. In unstimulated cells all the detected PKC isoforms showed a predominantly cytosolic localisation in normal and CML neutrophils. Cytosol-membrane distribution of PKC alpha and delta were significantly altered in leukemic neutrophils as compared to normal cells. Cytosolic levels of all PKC isoforms were reduced in CML neutrophils with PKC alpha, beta, iota, theta, and mu showing a significant decrease. Cytosolic levels of PKC delta contrary to the trend observed for other PKC isoforms showed a slight increase in CML cells, while its membrane levels were significantly reduced in CML neutrophils. Total PKC kinase activity in CML neutrophil cytosol was significantly reduced, while specific kinase activity of two representative isoforms, PKC alpha and delta, from normal and CML neutrophils were similar, thereby increasing the significance of the altered levels of PKC isoforms in CML, and highlighting their role in the defects in function exhibited by the leukemic neutrophils. The levels of PKC delta and iota increased and decreased respectively as the leukemic myeloid cell matured from the blast to the neutrophil, while the levels of PKC alpha and beta were not altered. This suggests a role for PKC delta and iota in the maturation of the leukemic myeloid cell.