Palliative care in India: current progress and future needs

Despite its limited coverage, palliative care has been present in India for about 20 years. Obstacles in the growth of palliative care in India are too many and not only include factors like population density, poverty, geographical diversity, restrictive policies regarding opioid prescription, workforce development at base level, but also limited national palliative care policy and lack of institutional interest in palliative care. Nonetheless we have reasons to be proud in that we have overcome several hurdles and last two decades have seen palpable changes in the mindset of health care providers and policy makers with respect to need of palliative care in India. Systematic and continuous education for medical staff is mandatory, and a major break-through for achieving this purpose would be to increase the number of courses and faculties in palliative medicine at most universities.

Concurrent therapy to enhance radiotherapeutic outcomes in glioblastoma

Glioblastoma is one of the most fatal and incurable human cancers characterized by nuclear atypia, mitotic activity, intense microvascular proliferation and necrosis. The current standard of care includes maximal safe surgical resection followed by radiation therapy (RT) with concurrent and adjuvant temozolomide (TMZ). The prognosis remains poor with median survival of 14.6 months with RT plus TMZ. Majority will have a recurrence within 2 years from diagnosis despite adequate treatment. Radiosensitizers, radiotherapy dose escalation and altered fractionation have failed to improve outcome. The molecular biology of glioblastoma is complex and poses treatment challenges. High rate of mutation, genotypic and phenotypic heterogeneity, rapid development of resistance, existence of blood-brain barrier (BBB), multiple intracellular and intercellular signalling pathways, over-expression of growth factor receptors, angiogenesis and antigenic diversity renders the tumor cells differentially susceptible to various treatment modalities. Thus, the treatment strategies require personalised or individualized approach based on the characteristics of tumor. Several targeted agents have been evaluated in clinical trials but the results have been modest despite these advancements. This review summarizes the current standard of care, results of concurrent chemoradiation trials, evolving innovative treatments that use targeted therapy with standard chemoradiation or RT alone, outcome of various recent trials and future outlook.

Ovarian granulosa cell tumor: clinical features, treatment, outcome, and prognostic factors

BACKGROUND

Granulosa cell tumors are rare neoplasms characterized by long natural history and favorable prognosis.

AIMS

The objective of this study was to determine the clinical presentation, treatment, outcome, and prognostic factors for patients of granulosa cell tumors.

MATERIALS AND METHODS

A retrospective analysis of 26 patients of granulosa cell tumor of ovary from 2002 to 2011 was carried out. The records of all patients were analyzed to determine clinical presentation, treatment, survival, and prognostic factors.

RESULTS

The median age of the patients was 50 years (range, 17-71 years). Abdominal pain was the most common presenting symptom. The median follow-up was 71.4 months (range, 21.6-149.9 months). The estimated 5 and 10 year overall survival (OS) was 84.6 and 72.5%, respectively. Event-free survival (EFS) was 76.5 and 52.9% at 5 and 10 years, respectively. Advanced stage was significant independent poor prognostic indicator for both OS and EFS.

CONCLUSION

Majority of the patients with granulosa cell tumors of the ovary present in early stage. Surgery is the primary treatment modality for granulosa cell tumors. Advanced stage and presence of residual disease were associated with inferior survival, but only prospective studies can ascertain their definite role.

Sarcomas of uterine cervix: clinicopathological features, treatment, and outcome

OBJECTIVE

Sarcomas constitute less than 1% of all cervical malignancies. The objective of this study was to determine the presentation, pathological findings, treatment, and outcome of patients with cervical sarcoma.

METHODS AND MATERIALS

A retrospective analysis of 8 cases of cervical sarcoma diagnosed over a 4-year period from 2006 to 2009 was carried out. The medical records of all patients were reviewed. All pathologic specimens were reviewed by a single pathologist.

RESULTS

Of 1804 patients with cervical malignancies, 8 cervical sarcomas were identified. All patients presented with vaginal bleeding and discharge. The lesions were clinically staged as IB2 (3), II B (1) and IIIB (4). Three patients had leiomyosarcoma, 4 patients had a diagnosis of undifferentiated endocervical sarcoma, and one had embryonal rhabdomyosarcoma. Of the 8 patients, 3 absconded after diagnosis. Primary surgery was done in 3 patients of which 2 patients received adjuvant radiotherapy and chemotherapy and one patient absconded after surgery. Primary radiotherapy was given in 2 patients. Three of 8 patients treated with combined modality treatment remain alive and disease free at the last follow-up.

CONCLUSIONS

Cervical sarcomas are rare neoplasms and represent a spectrum on histopathology. Most patients present with vaginal bleeding and a bulky cervical mass at the time of diagnosis. The optimal management of these tumors is uncertain owing to its rarity; however, combined modality treatment can result in prolonged survival and cure.

Small bowel adenocarcinoma: An overview

Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract. However, these tumors are among those with worst prognosis. Vague clinical signs and symptoms and radiological diagnostic challenges often delay treatment, which negatively impacts the prognosis of the patients. However, recent advances in imaging technology, like multidetector computed tomography, magnetic resonance imaging, and capsule endoscopy, have made earlier and accurate diagnosis possible. Surgery is the treatment of choice followed by adjuvant therapy. However, there are no strict treatment guidelines available for the management of SBA. Most of the available evidence from colorectal and gastric carcinoma has been extrapolated to adequately manage SBA. Prognosis for SBA is better than gastric carcinoma but worse than colorectal carcinoma. Currently, there is not enough information on the molecular characteristics and tumor pathogenesis. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.

Impact of volume of irradiation on survival and quality of life in glioblastoma: a prospective, phase 2, randomized comparison of RTOG and MDACC protocols

BACKGROUND

Though conformal partial-brain irradiation is the standard adjuvant treatment for glioblastoma, there is no consensus regarding the optimal volume that needs to be irradiated. European Organisation for Research and Treatment of Cancer (EORTC) and The University of Texas MD Anderson Cancer Center (MDACC) guidelines differ from the Radiation Therapy Oncology Group (RTOG) in their approach toward peritumoral edema, whereas RTOG and MDACC guidelines differ from EORTC in the concept of boost phase. A scarcity of randomized comparisons has resulted in remarkable variance in practice among institutions.

METHODS

Fifty glioblastoma patients were randomized to receive adjuvant radiotherapy using RTOG or MDACC protocols. Apart from dosimetric and volumetric analysis, acute toxicities, recurrence patterns, progression-free survival (PFS), overall survival (OS), and quality of life (QoL) were compared using appropriate statistical tests.

RESULTS

Both groups were comparable with respect to demographic characteristics. Dosimetric analysis revealed significantly lower boost-phase planning treatment volumes and V60 Gy in the MDACC arm (chi-squared, P = .001 and .013, respectively). No significant differences were observed in doses with respect to organs at risk, acute toxicity, or recurrence patterns (chi-squared, P > .05). On the log-rank test, median PFS (8.8 months vs 6.1 months, P = .043) and OS (17 months vs 12 months, P = .015) were statistically superior in the MDACC group.Age, extent of resection, and proportion of whole brain receiving prescription dose were associated with improved PFS and OS on regression analysis. QoL of patients was significantly better in the MDACC group in all domains except cognitive, as assessed with the EORTC Quality of Life Questionnaire (QLQ-C30) and Brain Cancer Module (QLQ-BN20) (general linear model, P < .05).

CONCLUSIONS

Use of limited-margin MDACC protocol can potentially improve survival outcomes apart from QoL of glioblastoma patients, as compared with the RTOG protocol.

Evaluation of outcome and prognostic factors in patients of glioblastoma multiforme: A single institution experience

AIMS

We present retrospective analysis of patients of glioblastoma multiforme (GBM) and discuss clinical characteristics, various treatment protocols, survival outcomes, and prognostic factors influencing survival.

MATERIALS AND METHODS

From January 2002 to June 2009, 439 patients of GBM were registered in our department. The median age of patients was 50 years, 66.1% were males, and 75% underwent complete or near-total excision. We evaluated those 360 patients who received radiotherapy (RT). Radiotherapy schedule was selected depending upon pre-RT Karnofsky Performance Status (KPS). Patients with KPS < 70 (Group I, n = 48) were planned for RT dose of 30-35 Gy in 10-15 fractions, and patients with KPS ≥ 70 (Group II, n = 312) were planned for 60 Gy in 30 fractions. In group I, six patients and in group II, 89 patients received some form of chemotherapy (lomustine or temozolomide).

STATISTICAL ANALYSIS USED

Statistical analysis was done using Statistical Package for Social Sciences, version 12.0. Overall survival (OS) was calculated using Kaplan-Meier method, and prognostic factors were determined by log rank test. The Cox proportional hazards model was used for multivariate analysis.

RESULTS

The median follow-up was 7.53 months. The median and 2-year survival rates were 6.33 months and 2.24% for group I and 7.97 months and 8.21% for group II patients, respectively (P = 0.001). In multivariate analysis, site of tumor (central vs. others; P = 0.006), location of tumor (parietal lobe vs. others; P = 0.003), RT dose (<60 Gy vs. 60 Gy; P = 0.0001), and use of some form of chemotherapy (P = 0.0001) were independent prognostic factors for survival.

CONCLUSIONS

In patients with GBM, OS and prognosis remains dismal. Whenever possible, we should use concurrent and/or adjuvant chemotherapy to maximize the benefits of post-operative radiotherapy. Patients with poor performance status may be considered for hypofractionated RT schedules, which have similar median survival rates as conventional RT.

Dosimetric and clinical outcome in image-based high-dose-rate interstitial brachytherapy for anal cancer

PURPOSE

To evaluate dosimetric and clinical outcome in patients of anal cancer treated with image-based interstitial high-dose-rate brachytherapy following chemoradiation.

METHODS AND MATERIALS

Sixteen patients with anal cancer were treated with chemoradiation followed by brachytherapy boost with image-based high-dose-rate interstitial brachytherapy from January 2007 to June 2011. Two brachytherapy dose schedules were used: 21 Gy in seven fractions and 18 Gy in six fractions depending on response to chemoradiation. CT scan was done after placement of needles for confirmation of placement and treatment planning. Target volume was contoured on CT scans. Volumetric quality indices and dose parameters were calculated.

RESULTS

The mean clinical target volume was 17.7 ± 4.98 cm(3), and the median overall tumor size was 4.2cm (3.4-5cm). The mean values of coverage index, dose homogeneity index, overdose volume index, dose non-uniformity ratio, and conformal index were 0.94, 0.83, 0.21, 0.37, and 0.88, respectively. With a median followup of 41 months (range, 20-67.2 months), preservation of the anal sphincter was achieved in 14 patients. The 1- and 2-year local control rates were 93.8% and 87.5%, respectively. Treatment was well tolerated and none of the patients developed Grade 3 or higher late toxicity.

CONCLUSIONS

The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and limits the volume of irradiated normal tissue, thereby decreasing late toxicity. The use of image-based treatment planning provides better dose conformality with reduced toxicity and helps to prevent a geographic miss.

Primitive neuroectodermal tumor of the uterine cervix diagnosed during pregnancy: a rare case with review of literature

Primitive neuroectodermal tumors of the cervix are very rare. A 28-year-old pregnant woman presented with a cervical mass. The tumor was staged as IB2. The biopsy from tumor was suggestive of malignant small round cell tumor. She then underwent termination of pregnancy followed by radical hysterectomy. Based on morphologic and immunohistochemical profile, a diagnosis of peripheral primitive neuroectodermal tumor of the cervix was made. The patient received adjuvant chemotherapy and radiotherapy. The patient is alive and disease-free 33 months post-surgery. The present case highlights the importance of keeping primitive neuroectodermal tumors in the differential diagnosis of small cell neoplasms of the uterine cervix. Pregnancy should not be a barrier to early detection and treatment of this potentially aggressive tumor. The optimal treatment methods have not yet been established because of the rarity of the tumor.

Leiomyosarcoma of the vagina: A rare entity with comprehensive review of the literature

Primary malignant lesions of the vagina are uncommon, and vaginal sarcomas are even rarer. We describe a rare case of stage I, high-grade leiomyosarcoma of the vagina treated with combined modality treatment. A 39-year-old female presented with vaginal mass and underwent resection. Histopathological examination revealed atypical leiomyoma of the vagina with definite risk of recurrence. Eleven months later, she presented with a recurrent vaginal mass and underwent exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy plus resection of recurrent tumor and partial vaginectomy. The detailed histopathological examination was suggestive of leiomyosarcoma of the vagina. The patient received adjuvant radiotherapy and chemotherapy. The patient is alive and disease-free 29 months postsurgery. Experience with vaginal leiomyosarcomas is limited. The optimal treatment methods have not yet been established because of the rarity of the tumor. We add another case of leiomyosarcoma of the vagina to the limited existing literature.

Survival and failure outcomes in locally advanced esthesioneuroblastoma: a single centre experience of 15 patients

Esthesioneuroblastoma (ENB) constitutes 3 % of all malignant intranasal tumors. As the tumor is very rare, the number of patients of ENB treated in individual departments is small. We present our institute's experience in combined modality management of 15 successive patients of ENB treated from 2006 to 2010. Clinical characteristics and treatment modality in form of surgery, radiotherapy and chemotherapy were noted. Kadish stage C was the most common stage (12 patients) followed by stage B (3 patients). Fourteen patients underwent primary surgery, of which nine had total excision and five had subtotal excision. One patient was treated with combination of chemotherapy (CT) and radiotherapy (RT). Median RT dose delivered was 54 Gy. Twelve patients received CT with cisplatin and etoposide. Overall, eight patients had complete response, five had partial response, while one had static disease and progressive disease each. Two patients had distant metastases. Four-year loco-regional control (LRC) was 25 % and 4-year overall survival (OS) was 45 %. Most common presentation in our series was locally advanced tumors. Most of these patients require adjuvant RT, which helps in significant LRC. Systemic CT benefits in inoperable, advanced and high risk tumors. Risk-adapted and multimodality approach is the need of hour to achieve good control rates while minimizing treatment related toxicity.

Low-grade myofibroblastic sarcoma of the larynx: a rare entity with review of literature

Mesenchymal neoplasms of the larynx are rare and make up approximately 0.3% to 1.0% of all malignancies at this location. Low grade myofibroblastic sarcoma (LGMS) of larynx is a rare entity. We describe a rare case of LGMS of larynx who presented with complaint of hoarseness of voice. The patient was treated with total laryngectomy plus partial pharyngectomy followed by post-operative radiotherapy. Histopathologically, the lesion was composed of spindle cells that manifested variable cellular anaplasia and expressed smooth muscle actin (SMA) and focally S-100.One of the resection limits was involved so patient was given post-operative radiotherapy. The patient is alive and disease free 14 months after surgery. The characteristic clinical, histopathological features and treatment of this case are described with a literature review.

Quadruple malignancy in a single patient: a case report and comprehensive review of literature

The occurrence of multiple primary malignant neoplasias (MPMN) is a rare but increasingly frequently reported event. Many theories have been proposed to explain MPMNs, but none have been proven. The key risk factors appear to be smoking and family history. While numerous studies have been published on the development of second malignancies following a first primary, the literature contains only few case reports and reviews of patients with three or more malignancies. We report a case of a young female who, over a period of 30 years, developed four different malignancies and was treated radically on each occasion.

Pediatric astroblastoma: a rare case with a review of the literature

Astroblastoma is a rare glial tumor with uncertain histopathological origin and unpredictable clinical behavior. We present a case of an 11-year-old girl who presented with headache and blurring of vision for 2 months. A well-demarcated mass was found in the right frontoparietal lobe on a brain MRI. The patient was treated with total tumor resection followed by postoperative radiotherapy. Histologically, the features were suggestive of high-grade astroblastoma. The patient is alive and disease free 23 months after surgery. The characteristic radiological and histopathological features and treatment of this case are described with a literature review.

Survival and failure outcomes in primary thyroid lymphomas: a single centre experience of combined modality approach

Primary thyroid lymphoma (PTL) is a rare malignancy and represents 2%-5% of all thyroid malignancies and 1%-2.5% of all malignant lymphomas. We present our institute's experience in combined modality management of 16 successive patients of PTL treated from 2005 to 2010. The median age of the patients was 56.0 years. Five patients were males, and 11 patients were females. An enlarging thyroid mass was the most common presenting symptom. 14 patients had diffuse large B-cell lymphoma, and 2 patients had follicular lymphoma. The most common stage of presentation was stage II comprising 6 (37.5%) patients. All patients received CCT, and only 12 patients received involved field RT with a median dose of 36.0 Gy. 10 patients (62.5%) had CR, and 6 patients (27.5%) had PR. Eight patients had disease progression in subsequent followup and this included the initial 6 patients with PR. The 5-year DFS was 40.0%, and median DFS was 47 months. The 5-year OS was 41.0%, and median OS was 51 months. Most common presentation in our series was locally advanced tumors. Most of these patients require combined modality management. Risk-adapted and multimodality approach is the need of the hour to achieve good control rates while minimizing treatment related toxicity.

Adult rhabdomyosarcoma: Clinical presentation, treatment, and outcome

OBJECTIVE

Rhabdomyosarcoma (RMS) in adults is a rare malignancy. The objective of our study was to determine presentation, treatment, patterns of failure, and outcome in this disease.

MATERIALS AND METHODS

A retrospective analysis of 25 patients of adult (>16 years) RMS who were treated at our institute from 2000 to 2009 was carried out. Tumors were classified according to the Intergroup Rhabdomyosarcoma Study (IRS) staging. All patients were treated with multimodality treatment except for three patients who received chemotherapy as the only modality.

RESULTS

The median age was 19 years (range, 16-68 years). The most common site was head and neck (52%) followed by extremities (24%), genitourinary (20%), and retroperitoneal RMS (4%). Three out of 25 patients presented with distant metastasis. With a median follow-up of 45 months, the 5-year overall survival (OS) rate was 45%. The 5-year local control (LC) rate was 53%. IRS grouping and complete response after primary therapy were predictors of a better survival.

CONCLUSIONS

RMS in adults have poor prognosis as compared to childhood RMS. Adult RMS should therefore be treated aggressively with multidisciplinary approach comprising of surgery, radiation, and chemotherapy to achieve cure and prolonged survival.

177Lu-DOTATATE Plus Radiosensitizing Capecitabine Versus Octreotide Long-Acting Release as First-Line Systemic Therapy in Advanced Grade 1 or 2 Gastroenteropancreatic Neuroendocrine Tumors: A Single-Institution Experience

PURPOSE

To compare the efficacy and safety of 177Lu-DOTATATE plus radiosensitizing capecitabine and octreotide long-acting release (LAR) as first-line systemic therapy in advanced well-differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs).

MATERIALS AND METHODS

Data of consecutive patients of advanced inoperable or metastatic grade 1 or 2 GEP-NETs treated with first-line 177Lu-DOTATATE plus radiosensitizing capecitabine or octreotide LAR from September 2012 to December 2019 were collected and analyzed for response, toxicity, and survival outcomes.

RESULTS

Seventy-six patients (median age: 53 years; range 14-81 years) with treatment-naïve advanced grade 1 or 2 GEP-NETs were included. Thirty-six patients received a median cumulative dose of 27.3 GBq of 177Lu-DOTATATE intravenously at 8-12 weeks' intervals along with 1,250 mg/m2 oral capecitabine on days 0-14 of each cycle of 177Lu-DOTATATE, whereas 40 patients were administered 30 mg octreotide LAR intramuscularly every 4 weeks. Using response evaluation criteria in solid tumor 1.1, the objective response rate was 38% in the 177Lu-DOTATATE arm compared with 15% in the octreotide LAR arm (P = .025), whereas the disease control rates were 88% and 67% in 177Lu-DOTATATE and octreotide LAR arms, respectively (P = .035). The median durations of progression-free survival in the 177Lu-DOTATATE and octreotide LAR arms were 54 months and 16 months, respectively (P = .017), whereas the median overall survival was not reached and not significantly different across both the arms. Of the treatment-related adverse events, no major difference was observed in the occurrence of grade 3 or 4 toxicities between the two treatment arms.

CONCLUSION

First-line systemic 177Lu-DOTATATE plus radiosensitizing capecitabine achieved better radiologic response and longer progression-free survival compared with octreotide LAR in patients with advanced grade 1 or 2 GEP-NETs. Future randomized controlled trials are, however, required to determine the best treatment sequence for the treatment-naïve patients with advanced GEP-NETs.

Five-year follow up of patients with gastrointestinal stromal tumor: recurrence-free survival by risk group

AIM

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. There is limited published data on GIST from the Indian subcontinent. This 5-year retrospective analysis of 49 patients treated for GIST reports clinical and pathological features and survival outcome by risk stratification.

METHODS

We reviewed 49 cases of GIST from January 2004 to December 2008. Imatinib was administered after surgery in patients with either high-risk, residual or metastatic disease and at onset of recurrence or metastatic disease in patients with intermediate risk.

RESULTS

The mean age was 50 years (range, 17-80 years). Patients with localized tumor were classified as low (n = 2), intermediate (n = 4) and high risk (n = 32), based on the primary tumor and mitotic index. At a median follow up of 21 months, 2-year and 3-year recurrence or progression-free survival rates were 61 and 39%, respectively, for all patients. The median recurrence-free survival rate in the intermediate-risk and high-risk groups were 7 and 49 months, respectively. The median progression-free survival in the residual (n = 4) and metastatic disease group (n = 7) was 10 and 29 months, respectively.

CONCLUSION

This study demonstrates the role of imatinib in adjuvant and therapeutic settings. Responses have been durable and most patients tolerate the drug well at clinically effective doses. In view of high recurrence rates in the intermediate-risk group in our study, it would be better to keep these patients on strict follow up to detect recurrence at the earliest opportunity.

Correlation of higher levels of soluble TNF-R1 with a shorter survival, independent of age, in recurrent glioblastoma

The circulating levels of soluble tumor necrosis factor receptor-1 (sTNF-R1) and sTNF-R2 are altered in numerous diseases, including several types of cancer. Correlations with the risk of progression in some cancers, as well as systemic manifestations of the disease and therapeutic side-effects, have been described. However, there is very little information on the levels of these soluble receptors in glioblastoma (GBM). Here, we report on an exploratory retrospective study of the levels of sTNF-Rs in the vascular circulation of patients with GBM. Banked samples were obtained from 112 GBM patients (66 untreated, newly-diagnosed patients and 46 with recurrent disease) from two institutions. The levels of sTNF-R1 in the plasma were significantly lower in patients with newly-diagnosed or recurrent GBM than apparently healthy individuals and correlated with the intensity of expression of TNF-R1 on the tumor-associated endothelial cells (ECs) in the corresponding biopsies. Elevated levels of sTNF-R1 in patients with recurrent, but not newly-diagnosed GBM, were significantly associated with a shorter survival, independent of age (p = 0.02) or steroid medication. In contrast, the levels of circulating sTNF-R2 were significantly higher in recurrent GBM than healthy individuals and there was no significant correlation with expression of TNF-R2 on the tumor-associated ECs or survival time. The results indicate that larger, prospective studies are warranted to determine the predictive value of the levels of sTNF-R1 in patients with recurrent GBM and the factors that regulate the levels of sTNF-Rs in the circulation in GBM patients.

Survival and failure patterns in atypical and anaplastic meningiomas: A single-center experience of surgery and postoperative radiotherapy

INTRODUCTION

Intracranial meningiomas are the second most common tumor of the CNS. The high-grade tumors are atypical and malignant meningioma comprising 5-7% and 1-3% of all meningiomas. The high-grade meningioma have an aggressive histopathological and clinical behavior.

MATERIALS AND METHODS

We retrospectively reviewed 37 patients of high-grade meningioma treated in our institute from 2002 to 2011. Clinical characteristics and treatment modality in form of surgery and radiotherapy (RT) were noted. Statistical analysis was done with regards to progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier survival analysis.

RESULTS

The median age of the patients was 45.0 years. The median duration of symptoms was 6 months. Headache was the most common presenting symptom. Fourteen patients underwent complete excision, while 23 had subtotal excision. Twenty-two patients had World Health Organization (WHO) grade II histology tumors and 15 patients had grade III histology. Median RT dose delivered was 50 Gy for grade II tumors and 54 Gy for grade III tumors. Five-year PFS for grade II and III tumors was 58 and 20%, respectively. Five-year OS for grade II and III tumors was 83 and 23%, respectively.

CONCLUSIONS

High-grade meningiomas represent a rare and aggressive neoplasm. The mainstay of therapy is gross total resection (GTR) at the initial surgery. Postoperative adjuvant RT should be offered to all patients, regardless of the degree of resection achieved. Long-term follow-up is important as local recurrences and progression can develop years after the initial treatment.

Urachal carcinoma: clinicopathological features, treatment and outcome

INTRODUCTION

Urachal carcinoma is a rare malignancy of urogenital tract. The objective of this study was to assess the clinical presentation, histopathological findings, treatment and outcome of patients of urachal carcinoma at a tertiary care centre.

MATERIALS AND METHODS

A retrospective analysis of six cases of urachal carcinoma diagnosed over a period of 7 years from 2005 to 2011 was carried out. All pathologic specimens were reviewed by a single pathologist. Clinical and histological features along with treatment were reviewed and patient follow-up and survival outcome was obtained.

RESULTS

The mean age at diagnosis was 36 years. Of the six patients, five were male. The tumor was located in dome in five and dome and anterior wall in one patient. All patients underwent partial cystectomy with bilateral pelvic lymph node dissection. The Sheldon pathologic stage was stage II in 1, IIIA in 2, IVA in 3 cases. Five out of six patients received adjuvant radiotherapy. The mean follow-up period was 37 months. Three out of six were disease free at last follow-up.

CONCLUSIONS

Urachal carcinomas are rare and usually locally advanced at presentation with a high risk of distant metastases. Surgery is the primary treatment of choice. Adjuvant therapy may decrease the chances of recurrence but it needs to be elucidated by prospective trials.

Paratesticular rhabdomyosarcoma in young adults: A tertiary care institute experience

INTRODUCTION

Paratesticular rhabdomyosarcoma (RMS) is a rare tumor arising from the mesenchymal tissues of the spermatic cord, epididymis, testis and testicular tunics. It represents only 7% of all patients entered in the Intergroup Rhabdomyosarcoma Study (IRS) and 17% of all malignant intrascrotal tumors in children less than 15 years old. We present our experience in combined modality management of 10 successive patients of paratesticular RMS.

MATERIAL AND METHODS

We retrospectively reviewed 10 patients of paratesticular RMS treated in our institute from July 2004 to December 2010. Clinical characteristics and treatment modality in form of surgery and chemotherapy (CCT) were noted. Statistical analysis was done with regards to progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier survival analysis.

RESULTS

The median age of the patients was 16.5 years. The median duration of symptoms was 5 months. Five patients had retroperitoneal lymphadenopathy (RPLAP) while three had lung metastases and one had orbital metastases. All patients underwent high inguinal orchidectomy followed by systemic chemotherapy (CCT). Retroperitoneal node dissection was not a required staging procedure. Four patients had partial response to treatment while six had complete response. Mean duration of PFS was 48 months and mean OS was 56 months.

CONCLUSIONS

Paratesticular RMS are rare neoplasms with aggressive growth patterns. Cure rates have dramatically improved and 60% of patients in our series had complete response. This success is due to development of multimodality and risk adapted treatment approaches.

A retrospective analysis of clinicopathological characteristics, treatment, and outcome of 27 patients of primary intestinal lymphomas

PURPOSE

Primary intestinal lymphomas comprise of a wide variety of histological subtypes with varied presentation. The objective of this study was to determine the presentation, histological type, treatment, and outcome of patients of primary intestinal lymphoma.

METHODS

A retrospective analysis of 27 patients of primary intestinal lymphoma treated at our institute from 2004 to 2010 was carried out. Patients were staged according to Musshoff's modification of Ann Arbor classification.

RESULTS

The median age was 51 years (range, 7-76 years). Abdominal pain was the most common presenting symptom followed by mass abdomen, loss of appetite, constipation, and vomiting. The most common site of disease presentation was ileocecal region and jejunum. Diffuse large B cell lymphoma was the predominant histological type observed in 55.6%. Eighteen patients underwent surgery with or without chemotherapy. Chemotherapy, either alone or with radiotherapy, was given to nine patients. The median follow-up was 48.3 months (range 5-94 months). The 5-year overall survival (OS) and event-free survival were 53.5 and 53%, respectively. The 5-year OS for patients who underwent both surgery and chemotherapy was 79.5% and for those without surgery was 13.9%, respectively.

CONCLUSION

Primary intestinal lymphomas are heterogenous diseases. Patients who underwent surgery had better survival and outcome than those without surgery. Chemotherapy is necessary for improving the survival of these patients. Optimal management is still uncertain due to the rarity of this disease.

Hematological Markers as Predictors of Treatment Outcomes with Lutetium 177 (177Lu)-DOTATATE in Patients with Advanced Neuroendocrine Tumors

Background: Chronic inflammation has been linked to the development and prognosis of neuroendocrine tumors (NETs). The current study intended to evaluate the role of peripheral hematological inflammatory markers, viz. the platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio, and monocyte-lymphocyte ratio, as predictors of treatment outcomes in patients with advanced NETs after Lutetium-177(177Lu)-DOTATATE therapy. Materials and Methods: Data of consecutive patients with advanced metastatic and/or inoperable NETs treated with 177Lu-DOTATATE from the year 2012 to 2019 at the authors' center were retrospectively analyzed. Results: Forty-two NET patients (median age: 49.5 years) received a median cumulative activity of 29.6 GBq of 177Lu-DOTATATE over 2-5 cycles at 8-12-week intervals. The median progression-free survival (PFS) of the study cohort was 30 months (95% confidence interval, CI: 18.2-41.9 months). A baseline PLR ≥173.1 was found to be a significant predictor of poor PFS with a univariate hazard ratio of 3.82 (95% CI: 1.21-12.03); however, the association was not significant on multivariate analysis. The median overall survival was not reached and none of the parameters were significantly associated with it. Conclusions: A higher baseline PLR was shown to be associated with a negative outcome on PFS after 177Lu-DOTATATE therapy and is a promising marker for future larger studies.