Gut Colonization with Carbapenem-resistant Enterobacteriaceae Adversely Impacts the Outcome in Patients with Hematological Malignancies: Results of A Prospective Surveillance Study

BACKGROUND

Gut colonisation with carbapenem-resistant enterobacteriaceae (CRE) is a risk factor for CRE bacteremia and patients with haematological malignancies (HM) are at the highest risk of mortality.

METHODS

We conducted a prospective surveillance study of gut colonisation with CRE and its impact on the outcome of 225 consecutive patients of HM over 28 months.

RESULTS

The median age of the cohort was 46 years, the majority with acute leukaemia. 48 (21%) patients were colonised with CRE on admission (CAD). Another 46 patients were colonised with CRE in the hospital (CIH). The risk factors for CAD and CIH were a diagnosis of acute leukaemia and duration of hospital stay respectively. CRE accounted for 77% of infection-related mortality (IRM). The incidence of CRE bacteremia in CRE positive patients was 18% (17/94), and mortality in those with CRE bacteremia was 100%. IRM was 35.3% in CIH group compared to 10.5% in the CAD group (p=0.0001). IRM was highest in those with acute myeloid leukaemia (AML) and CIH (54.9% p=0.0001). On multivariate analysis, CIH was the most important risk factor for IRM (HR-7.2).

CONCLUSION

Our data demonstrate that a substantial proportion of patients with HM are colonised with CRE without prior hospitalisation, but those with nosocomial colonisation have the highest risk of mortality, particularly in those with AML.

T cell costimulation blockade for hyperacute steroid refractory graft versus-host disease in children undergoing haploidentical transplantation

The outcome of hyperacute grade 3-4 steroid-refractory graft-versus-host-disease (SR-GVHD) remains dismal despite a plethora of agents being tried alone or in combination. Following T replete haploidentical transplantation with post-transplantation cyclophosphamide on 75 patients, 10 patients (13%) aged 2-20years, developed hyperacute SR-GVHD. We report on the outcome of two different regimens for treatment of SR-GVHD on the outcome of these patients. Five patients were treated in Regimen A consisting of anti-thymocyte globulin, Etanercept and Basiliximab. The next 5 patients were treated combining T cell costimulation blockade with Abatacept along with Etanercept and Basiliximab. The overall response at days 29 and 56 were 40% and 0% with Regimen A and100% and 40% with Regimen B. The major cause of treatment failure was progression of GVHD and opportunistic infections. Two of the patients achieving a complete remission on Regimen B are long term disease free survivors off immunosuppression. Our study demonstrates the dismal outcome of early onset SR-GVHD in children following T replete haploidentical transplantation. However, the combination of Abatacept with anticytokine agents seems to produce encouraging early response and might warrant further investigation.

Febrile neutropenia due to COVID-19 in an immunocompetent patient

While lymphopenia has been a common finding in COVID-19 infection, particularly in severe cases, febrile neutropenia has been very rarely reported in immunocompetent patients with COVID-19. Herein, we report the case of a 76-year-old hypertensive and diabetic man who was hospitalised with severe COVID-19 infection and developed delayed-onset severe neutropenia with neutropenic fever, which responded to treatment with antibiotics and granulocyte colony-stimulating factor. This case highlights the importance of identifying a rare complication (febrile neutropenia on the fifth week) of COVID-19 infection in hospitalised patients by intensive monitoring and aggressive management for favourable outcomes.

Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

INTRODUCTION

Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.

METHODS

Prospective cohort study in 109 institutions in 41 countries.

INCLUSION CRITERIA

children <18 years who were newly diagnosed with or undergoing active treatment for acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour, glioma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, medulloblastoma and neuroblastoma. Of 2327 cases, 2118 patients were included in the study. The primary outcome measure was all-cause mortality at 30 days, 90 days and 12 months.

RESULTS

All-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3-11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); p<0.001), lower middle income (OR 3.32 (95% CI 1.96 to 5.61); p<0.001) and upper middle income (OR 3.49 (95% CI 2.02 to 6.03); p<0.001) country status and chemotherapy (OR 0.55 (95% CI 0.36 to 0.86); p=0.008) and immunotherapy (OR 0.27 (95% CI 0.08 to 0.91); p=0.035) within 30 days from MDT plan. Multivariable analysis revealed laboratory-confirmed SARS-CoV-2 infection (OR 5.33 (95% CI 1.19 to 23.84); p=0.029) was associated with 30-day mortality.

CONCLUSIONS

Children with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.

Bone Marrow Metastases from Solid Organ Cancer in Adults

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

Two case reports of an unusual association between Klippel-Feil syndrome and amyotrophic lateral sclerosis: Do they share same genetic defect?

Klippel-Feil syndrome (KFS) is an unusual skeletal disorder characterized by congenital fusion of two or more cervical vertebrae which can be sporadic or familial. KFS emerges to be a failure of the normal segmentation and fusion of the mesodermal somites during 3(rd) and 8(th) weeks of embryonic development. The triad of low posterior hairline, short neck, and restricted neck motion is present only in 50% and often associated with scoliosis, spina bifida, Sprengel's deformity, cervical ribs, deafness, cleft palate, renal anomalies, congenital heart defects, and so on because of heterogeneous nature of the disease. The significance of KFS lies in the secondary effects produced on the nervous system, which usually presents with features of progressive cord and brain stem compression with relatively minor trauma. We here report two cases of KFS presented in association with amyotrophic lateral sclerosis. Only two such cases have been described in the literature in 1954 and 1975.

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

BACKGROUND

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

CASE

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

CONCLUSION

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

Metastatic Dermatosis in Breast Carcinoma on Adjuvant Trastuzumab: Is Skin a Sanctuary Site in Human Epidermal Growth Factor Receptor-2-Amplified Disease?

Cutaneous metastasis (CM) from internal malignancies is commonly seen. Sometimes, skin metastases can be the first sign of advanced cancer or an indicator of cancer recurrence. Cases of breast cancer with cutaneous progression after or during trastuzumab therapy have been described in the past, frequently associated with systemic disease progression. However, CM during adjuvant trastuzumab therapy is very rare. It has been hypothesized that cancer cells located in the skin survive and take proliferative advantage by virtue of an immune-tolerance mechanism that hampers trastuzumab-mediated antibody-dependent cell-mediated cytotoxicity. We describe a case of human epidermal growth factor receptor-2-overexpressing breast cancer presenting with diffuse CM during adjuvant trastuzumab therapy.

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

BACKGROUND

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

CASE

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

CONCLUSION

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

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

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

Exploring an Unfathomed Entiry: A Pooled Analysis of Solitory Skeletal Muscle Metastasis from Head and Neck Squamous Cell Carcinoma

BACKGROUND

Skeletal muscle is relatively uncommon site for metastasis in head and neck primary. This study was conducted to report our experience of three such cases and analyze the previously reported cases to assess the overall outcomes and formulate a treatment plan for these patients.

METHODS

We pooled the data extracted on extensive literature review and analyzed.

RESULTS

A total of 17 patients were analyzed for this study. All the patients had locally advanced primary and 14/17 developed metachronous metastasis. Median duration to development of metastasis was 8.5 months, and 13/17 patients had skeletal muscle as the only site of metastasis. Only 6/13 were treated with aggressive intent, 4 of which who underwent surgical resection had the best survival outcomes.

CONCLUSIONS

Isolated skeletal muscle metastasis in a head and neck primary is relatively rare, and in future, the research work needs to be taken up afresh, on prospective model, with adequate patient sample, to draw a scientifically valid conclusion.

Demographic and clinicopathological Profile of Gall Bladder Cancer Patients: Study from a tertiary care center of the Sub-Himalayan region in Indo-Gangetic Belt

INTRODUCTION

Gall bladder cancer (GBC) accounts for 80%-95% of biliary tract malignancies in the world. There is however striking variability in the global incidence of gallbladder cancer, reaching epidemic levels for some regions and ethnicities. The aim of this study was to evaluate the demographic and clinicopathological profile of the gallbladder cancer patients.

MATERIALS AND METHODS

All patients of carcinoma gall bladder presenting to department of surgery in hepatopancreaticobiliary unit from July 2017 to November 2020 were included in this study. A proforma containing all the relevant details including history, examination, blood, radiology, and pathological investigations was filled.

RESULTS

A total of 326 patients of GBC were analyzed. The majority (75%) were found to be females with a mean age of 55 years. Pain abdomen was the most common presenting symptom in 81% of patients. The most common stage of presentation was stage IV and only 6 were in stage I. Two hundred and thirty three (71.4%) patients had metastatic disease at presentation. Liver infiltration at the time of diagnosis was present in 89% of patients. The most common site of metastasis was found in the liver (23.3%). GBC was more common in patients with A blood group. Baseline serum albumin levels were found to be significantly associated with the staging of GBC.

CONCLUSIONS

Due to the non specific symptoms patients of GBC present at very advanced stages, high index of suspicion and health education seems to play an important role in early detection and improvement of survival.

Prostatic Adenocarcinoma Incognito Manifestation as Generalized Lymphadenopathy: a Rare Case Report

Generalized lymphadenopathy is a rare manifestation of carcinoma prostate. Here, we report a case of a 73-year-old male who presented with left supraclavicular lymphadenopathy along with hoarseness of voice and weight loss. His CT neck, chest, abdomen, and subsequently18F-FDG PET CT were suggestive of generalized lymphadenopathy with skeletal involvement. He was not having any urinary or bone symptoms. The biopsy of supraclavicular lymph node revealed metastatic adenocarcinoma, whose prostatic origin was suggested by IHC staining of PSA. The diagnosis was confirmed by prostatic biopsy along with markedly raised serum PSA. We emphasize that in men with adenocarcinoma of undetermined origin, a suspicion of prostate cancer is important for accurate diagnosis and therapeutic approach.

Facial disfigurement due to olfactory neuroblastoma: beauty regained with chemotherapy

BACKGROUND

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

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

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

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

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

Efficacy and Safety of FOLFOX as a Second-Line Chemotherapy for Patients with Locally Advanced and/or Metastatic Carcinoma Gall Bladder – Experience from a Tertiary Care Center in India

Background: Carcinoma gallbladder is mostly diagnosed in locally advanced, inoperable, or metastatic stage. Best supportive care with or without palliative chemotherapy is the only feasible treatment option. Gemcitabine and platinum agents' combination is the most effective first option with no well-established second-line regimen. Objectives: We planned to study the response rate, safety, the progression-free survival (PFS), and overall survival (OS) on the second-line FOLFOX-4 chemotherapy. Methods: This is a prospective single-arm observational study of 29 eligible patients. Patients were studies for response to the second-line FOLFOX-4 chemotherapy. Positron emission tomography/computed tomography scans were done for response assessment; chemotherapy toxicity was graded using National Cancer Institute clinical toxicity criteria; and survival rates (PFS and OS) were studied. Results: Among the 39 patients with gemcitabine-based chemotherapy (CT-1), the median PFS-1 was 6.5 months. Twenty-nine patients received second-line chemotherapy (CT-2). Responses observed complete response in 2/29, partial response in 7/29, stable disease in 1/29 patients, and progressive disease in 19/29. The overall response rate was 9/29 (31.0%). Grades 2–4 toxicities were anemia (17.95%), thrombocytopenia (12.82%), neutropenia (12.82%), and peripheral neuropathy (7.69%). The median OS was 9.13 months. Late PFS-1 (>median PFS-1) patients had significantly lower mortality as compared to early PFS-1, odds ratio of 0.251 (P = 0.002), and median PFS-2 was 2.53 months. Conclusion: After the failure of gemcitabine and platinum-based chemotherapy, FOLFOX-4 is modestly effective, fairly well tolerated and this needs to be proven in a larger randomized phase 3 study. Further research into the pathogenesis of biliary tract cancer with the aim to identify new targets for treatments is required.

Maxillary Diffuse Large B-Cell Lymphoma Enshrouded as Osteomyelitis: A Case Report

Extranodal non-Hodgkin's lymphoma (NHL) afflicting the head and neck region is rare, accounting for only about 5%. Diffuse large B-cell lymphoma (DLBCL) is the most common type of NHL affecting the oral cavity. Due to its variable clinical presentation and non-pathognomic course, it can be easily misdiagnosed with overlapping characteristics to common oral pathologies. In the present case, the authors report an unusual presentation of DLBCL and highlight the significant diagnostic challenge encountered by the clinician. In our case, osteonecrosis of the maxilla with soft tissue swelling misleads the diagnosis of chronic osteomyelitis. However, further, work-up was pursued, and the patient was managed successfully with chemotherapy and is currently disease-free for the past 1 year. An accurate clinico-radiological diagnosis with histopathological confirmation is emphasized to deliver a potentially curative treatment in a timely manner.

Reply to A. Mathew et al

Gender disparities in young-onset CRC highlight health care access barriers in LMICs & changing global incidence trends. Increased awareness is crucial. #JCOGO @JCOGO_ASCO.

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

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