Biomarkers in triple negative breast cancer: A review

Breast cancer is an intrinsically heterogeneous disease. In the world about 1 million cases of breast cancer are diagnosed annually and more than 170000 are triple-negative. Characteristic feature of triple negative breast cancer (TNBC) is that it lacks expression of oestrogen, progesterone and human epidermal growth factor receptor-2/neu receptors. They comprise 15%-20% of all breast cancers. We did a systematic review of PubMed and conference databases to identify studies published on biomarkers in TNBC. We included studies with biomarkers including: Epidermal growth factor receptor, vascular endothelial growth factor, c-Myc, C-kit and basal cytokeratins, Poly(ADP-ribose) polymerase-1, p53, tyrosinase kinases, m-TOR, heat and shock proteins and TOP-2A in TNBC. We also looked for studies published on synthetic lethality and inhibition of angiogenesis, growth, and survival pathways. TNBC is a complex disease subtype with many subclasses. Majority TNBC have a basal-like molecular phenotype by gene expression profiling. Their clinical and pathologic features overlap with hereditary BRCA1 related breast cancers. Management of these tumours is a challenge to the clinician because of its aggressive behaviour, poor outcome, and absence of targeted therapies. As the complexity of this disease is being simplified over time new targets are also being discovered for the treatment of this disease. There are many biomarkers in TNBC being used in clinical practice. Biomarkers may be useful as prognostic or predictive indicators as well as suggest possible targets for novel therapies. Many targeted agents are being studied for treatment of TNBC.

Systemic treatment strategies for triple-negative breast cancer

Triple-negative breast cancer (TNBC) is defined by the lack of immunohistochemical expression of the estrogen and progesterone receptors and human epidermal growth factor receptor 2 (EGFR2). Most TNBC has a basal-like molecular phenotype by gene expression profiling and shares clinical and pathological features with hereditary BRCA1 related breast cancers. This review evaluates the activity of available chemotherapy and targeted agents in TNBC. A systematic review of PubMed and conference databases was carried out to identify randomised clinical trials reporting outcomes in women with TNBC treated with chemotherapy and targeted agents. Our review identified TNBC studies of chemotherapy and targeted agents with different mechanisms of action, including induction of synthetic lethality and inhibition of angiogenesis, growth and survival pathways. TNBC is sensitive to taxanes and anthracyclins. Platinum agents are effective in TNBC patients with BRCA1 mutation, either alone or in combination with poly adenosine diphosphate polymerase 1 inhibitors. Combinations of ixabepilone and capecitabine have added to progression-free survival (PFS) without survival benefit in metastatic TNBC. Antiangiogenic agents, tyrosine kinase inhibitors and EGFR inhibitors in combination with chemotherapy produced only modest gains in PFS and had little impact on survival. TNBC subgroups respond differentially to specific targeted agents. In future, the treatment needs to be tailored for a specific patient, depending on the molecular characteristics of their malignancy. TNBC being a chemosensitive entity, combination with targeted agents have not produced substantial improvements in outcomes. Appropriate patient selection with rationale combinations of targeted agents is needed for success.

Second primary in the contralateral breast after treatment of breast cancer

PURPOSE

To study the potential risk factors for contralateral breast cancer (CBC) in women after treatment of the primary breast cancer.

PATIENTS AND METHODS

Between January 1985 and December 1995, records of 1084 breast cancer patients at our institution were analyzed for incidence of CBC. In all the patients a detailed analysis was carried out with respect to age, disease stage, radiation therapy technique, dose, the use of chemotherapy or hormone therapy, and other clinical and/or pathologic characteristics. The Kaplan-Meier method was used to estimate the acturial rate of CBC. The Cox proportional hazard regression model was used to estimate the relative risk (RR) of CBC.

RESULTS

Up to December 2005, the median follow up was 12 years. Overall incidence of CBC was 4%. The 10 and 20 year acturial rate of CBC was 5.6% and 11.3%, respectively. The CBC rate at 10 and 20 year was 5.4% and 10.2%, respectively, for patients with mastectomy only and 5.1% and 9.7%, respectively, in the mastectomy plus RT group (p=0.3). In the subset of patients <45 years of age at the time of treatment, 10 and 20 year acturial rate of CBC was 5% and 9%, respectively, for patients who underwent mastectomy only and 6.3% and 11%, respectively, for patients treated with mastectomy plus RT (RR=1.4, 95% CI: 1.14-1.45, p=0.003). There was statistically significant lower rate of CBC in patients given adjuvant hormonal therapy (8.5%) as compared to those without hormonal therapy (14.3%, p=0.004) at 20 year. Women with family history of breast cancer had highest rate (15.3%) of CBC (RR=1.6, 95% CI: 1.12-1.27) at 20 years. The adjuvant use of chemotherapy did not significantly affect the risk of second malignancy.

CONCLUSION

There seems to be little risk of second malignancies in patients treated with mastectomy plus RT using modern techniques, compared with mastectomy only, that was only prevalent in patients <45 years of age. Family history of breast cancer seems to be the highest risk factor for CBC.

Orbital lymphoma: role of radiation

The purpose of this article is to review the literature for clinical presentation, treatment, outcome and complications of using radiotherapy for the treatment of orbital lymphoma. For this, MEDLINE, EMBASE, and the Cochrane Library were searched through January 2007 for published data on primary non-Hodgkin's lymphoma (NHL) of the orbit. The search was conducted in all document types, using the following terms "Non-Hodgkin's lymphoma, MALT (mucosa associated lymphoid tissue) and orbit". Data extracted were based on age, sex, therapeutic methods and outcome of treatment. When full articles were not available, abstracts were used as a source of information. Only those articles whose abstracts or full text were available in English were included in table. The review of reports of NHL of the orbit, in general, served as a source of information about its clinical behavior, treatment and overall prognosis. Fifty-six publications were identified, including six in languages other than English. There was no randomized trial. All the studies were retrospective. The studies were heterogeneous in patient number (3 to 112), histology, disease stage (IE to IV), radiotherapy doses used (4 to 53.8Gy), local control rates (65 to 100%), distant relapse rates (0 to 67%, from low grade to high grade) and five-year survival rates (33 to 100%). Three of the studies with a good number of patients also demonstrated clinical benefit with radiotherapy in terms of superior efficacy or less toxicity. Available data support the acceptance of radiotherapy as a standard therapeutic option in patients with low to intermediate grade orbital lymphoma. Toxicity of radiotherapy is mild if delivered precisely.

Patterns of relapse in locally advanced breast cancer treated with neoadjuvant chemotherapy followed by surgery and radiotherapy

AIMS

To define the clinical and pathological predictors of locoregional recurrence (LRR) in locally advanced breast cancer (LABC) patients treated with neoadjuvant chemotherapy (NACT).

MATERIALS AND METHODS

We retrospectively reviewed the outcome of 141 patients with stage II to stage III carcinoma breast treated at Department of Radiotherapy, PGIMER, Chandigarh from 1998-2002. Mean age of the patients was 46 years, 49% of patients were premenopausal and 51% were postmenopausal. The tumor stage was T2 in 18%; T3 in 61% and T4 in 26% of the patients. NACT regimen given was FAC (5-fluorouracil, adriamycin and cyclophosphamide) in 85% and CMF (cyclophosphamide, methotrexate and 5-Fu) in 15% patients.

RESULTS

After NACT, surgery was possible in 95% patients. Conservative surgery was possible in 23% patients and mastectomy was done in 72% of patients. Pathological complete response (pCR) was seen in 18% patients and pathological partial response (pPR) in 69% of patients. Stable and progressive disease was seen in 6% and 7% of patients respectively. Adjuvant radiation therapy was given to 86% patients. Six percent patients developed progressive disease and 4% of patients did not turn up for radiation. Five year LRR was 6% and relapse free survival (RFS) was 94%. Thirty-two (23%) patients developed distant metastasis resulting in distant metastasis free survival of 77%. The factors that correlated positively with LRR on univariate analysis included tumor stage, stage and pathological nodal stage. However, on multivariate analysis, tumor stage and pathological nodal stage were significant. Factors that correlated for distant relapse were tumor stage, response to chemotherapy, type of surgery, extracapsular extension (ECE) and tamoxifen therapy. On multivariate analysis only ECE was the significant factor that correlated with distant relapse free survival.

CONCLUSION

Thus, tumor stage and pathological nodal stage remains the most important predictor of LRR in LABC. Factors that correlated for distant relapse were tumor stage, response to chemotherapy, type of surgery and ECE and tamoxifen therapy.

Comparison of Toxicity and Cosmetic Outcomes After Accelerated Partial Breast Irradiation or Whole Breast Irradiation Using 3-Dimensional Conformal External Beam Radiation Therapy

PURPOSE

To compare rates of acute and late skin toxicities and cosmetic outcomes after accelerated partial breast irradiation (APBI) or whole breast irradiation (WBI) using 3-dimensional conformal external beam radiation therapy in women with breast cancer after breast conservation surgery (BCS).

METHODS AND MATERIALS

Women >35 years of age with invasive or noninvasive breast cancer ≤4 cm treated by BCS were randomized to 3D-CRT APBI (34 Gy/10 fractions/5 days) or WBI (40 Gy/16 fractions/3 weeks ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence. Important secondary outcomes were skin toxicities using Radiation Therapy Oncology Group scores, Late Effects Normal Tissue Task Force and Subjective, Objective, Management, Analytic scales, and adverse cosmetic outcome. This interim analysis focuses on the secondary endpoints of radiation toxicities and cosmesis. Patient and tumor characteristics and rates of adverse cosmetic outcomes and skin toxicities were compared using Fisher exact tests. All statistical tests were 2 sided, with P < .05 considered statistically significant.

RESULTS

Between June 2011 and December 2015, 133 women with breast cancer were randomized to 3D-CRT APBI or WBI. Patient and tumor characteristics were balanced between the 2 arms. Median follow-up was 60 months (range, 12-93 months). Grade 4 late toxicity was not seen in either of the treatment arms, and grade 3 toxicity was very low for each endpoint assessed in both the groups. The rates of grade ≥2 acute dermatitis were 8% and 15%, respectively, for APBI and WBI (P = .18). Rates of grade ≥1 late radiation toxicities were higher in the WBI arm compared with the APBI arm for breast shrinkage (P = .008), pigmentation (P = .028), fibrosis (P = .040), induration (P = .048), and edema (P = .33). Adverse cosmesis at last follow-up was significantly higher in patients treated with WBI: 33% compared with 6% with APBI (P < .001).

CONCLUSIONS

In women with breast cancer after BCS, APBI was associated with better cosmetic outcome and fewer late radiation toxicities than WBI.

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.

Nonbreast second malignancies after treatment of primary breast cancer

PURPOSE

To determine the incidence and risk factors for nonbreast second malignancies (NBSMs) in women after treatment for primary breast cancer.

METHODS AND MATERIALS

Between January 1985 and December 1995, a total of 1,084 breast cancer patients were analyzed for NBSMs. Detailed analysis was carried out for age, family history, disease stage, radiation therapy, chemotherapy, hormone therapy, other clinical/pathologic characteristics, and site of NBSMs. The Cox proportional hazard regression model was used to estimate the relative risk of NBSMs.

RESULTS

Median follow-up was 12 years. In total, 33 cases of NBSMs were noted in 29 patients. The overall incidence of NBSM was 3%, and the median time for NBSMs was 7 years. The most common NBSMs were gynecologic (22 patients), gastrointestinal (4 patients), head and neck (3 patients), hematologic (2 patients), lung (1 patient), and thyroid (1 patient). The NBSMs rate at 12 years was 2.4% for both mastectomy and radiation therapy groups. In the subset of patients less than 45 years of age at the time of treatment, the NBSMs rate was 0.7% as compared with 4.6% in patients more than 45 years of age (p = 0.001). Statistically significant higher incidences of endometrial and ovarian cancer were seen in patients with hormonal therapy (5.2%) as compared with patients without hormonal therapy (1.8%, p = 0.002). Women with a family history of breast cancer had a higher incidence (6%) of endometrial and ovarian malignancy compared with women without such a history (2.1%, p = 0.003). Chemotherapy did not affect the risk of second malignancy.

CONCLUSION

The most common NBSMs in this study were gynecologic. Family history of breast cancer was a high risk factor for NBSMs. No risk of NBSMs with radiotherapy was observed.

Late-term effects of hypofractionated chest wall and regional nodal radiotherapy with two-dimensional technique in patients with breast cancer

PURPOSE

Hypofractionated radiotherapy (RT) is becoming a new standard in postoperative treatment of patients with early stage breast cancer after breast conservation surgery. However, data on hypofractionation in patients with advanced stage disease who undergo mastectomy followed by local and regional nodal irradiation (RNI) is lacking. In this retrospective study, we report late-term effects of 3 weeks post-mastectomy hypofractionated local and RNI with two-dimensional (2D) technique in patients with stage II and III breast cancer.

METHODS

Between January 1990 and December 2007, 1,770 women with breast cancer who were given radical treatment with mastectomy, systemic therapy and RT at least 10 years ago were included. RT dose was 35 Gy/15 fractions/3 weeks to chest wall by two tangential fields and 40 Gy in same fractions to supraclavicular fossa (SCF) and internal mammary nodes (IMNs). SCF and IMNs dose was prescribed at dmax and 3 cm depth, respectively. Chemotherapy and hormonal therapy was given in 64% and 74% patients, respectively. Late-term toxicities were assessed with the Radiation Therapy Oncology Group (RTOG) scores and LENT-SOMA scales (the Late Effects Normal Tissue Task Force-Subjective, Objective, Management, Analytic scales).

RESULTS

Mean age was 48 years (range, 19 to 75 years). Median follow-up was 12 years (range, 10 to 27 years). Moderate/marked arm/shoulder pain was reported by 254 (14.3%) patients. Moderate/marked shoulder stiffness was reported by 219 (12.3%) patients. Moderate/marked arm edema was seen in 131 (7.4%) patients. Brachial plexopathy was not seen in any patient. Rib fractures were noted in 6 (0.3%) patients. Late cardiac and lung toxicity was seen in 29 (1.6%) and 23 (1.3%) patients, respectively. Second malignancy developed in 105 (5.9%) patients.

CONCLUSION

RNI with 40 Gy/15 fractions/3 weeks hypofractionation with 2D technique seems safe and comparable to historical data of conventional fractionation (ClinicalTrial.gov Registration No. XXXX).

A Phase 2 Study of 2 Weeks of Adjuvant Whole Breast/Chest Wall and/or Regional Nodal Radiation Therapy for Patients With Breast Cancer

PURPOSE

To report the results in terms of feasibility and early toxicity of hypofractionated adjuvant whole breast/chest wall and/or regional nodal radiation therapy for patients with breast cancer.

METHODS AND MATERIALS

From June 2013 to October 2014, 50 patients with breast cancer after mastectomy or after breast conservation surgery (BCS) were prospectively included. The institutional ethics committee approved the study, which was registered with ClinicalTrials.gov (ClinicalTrials.gov identifier no. NCT02460744). Treatment planning was performed using a simulator with 2 tangential fields to the breast/chest wall and an incident field to the supraclavicular fossa. The radiation dose delivered was 34 Gy in 10 fractions within 2 weeks, followed by a boost of 10 Gy in 5 fractions within 1 week for patients who underwent BCS. Acute skin toxicities were recorded during and after treatment according to the Radiation Therapy Oncology Group acute radiation toxicity scoring criteria. The primary objective was to obtain estimates of the acute toxicity rates and cosmetic outcomes that could be used to design a subsequent phase III comparative study. Acute skin and late toxicities were recorded during and after treatment. Cosmetic outcomes were assessed before and after treatment and during the regular follow-up period. A cost/benefit analysis was also performed and compared with that for standard treatment of 35 Gy in 15 fractions within 3 weeks.

RESULTS

The median follow-up was 39 months (range 14-48). The mean age was 51 years (range 26-75). A left-sided tumor was present in 25 patients (50%). Total mastectomy with axillary clearance was performed in 40 (80%) and BCS in 10 (20%) patients. Acute grade 2 and 3 skin toxicity was seen in 16 (32%) and 1 (2%) patient, respectively. In the BCS patients, grade 2 skin and subcutaneous toxicity was seen in 2 (20%) and 1 (10%) patient, respectively. Grade 2 edema was seen in 1 patient (10%). The cosmesis was excellent or good in 8 (80%) and fair or poor in 2 (20%) patients. The cost/benefit analysis revealed significantly less financial burden on the patients with 2 weeks of treatment. Disease-free and overall survival at 3 years was 94% and 96%, respectively.

CONCLUSIONS

Hypofractionated radiation therapy within 2 weeks appears to be feasible for patients with breast cancer and was associated with acute and late skin toxicity profiles similar to those observed with 3 weeks of treatment. The financial burden on the patient and family could be reduced with 2 weeks of treatment. Long-term follow-up data and a prospective comparative study are needed to strengthen these results. Hypofractionation might help radiation centers worldwide to meet the increasing need for radiation for breast cancer, especially in developing countries where resources are limited and patients must travel long distances for treatment.

Impact of acute hematological toxicity on treatment interruptions during cranio-spinal irradiation in medulloblastoma: a tertiary care institute experience

To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.

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.

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.

Postmastectomy radiation and survival in patients with breast cancer

PURPOSE

To analyze the impact of postmastectomy radiotherapy on locoregional control and overall survival in patients with carcinoma breast.

MATERIALS AND METHODS

Between 1995 and 2000, 688 patients of carcinoma breast were analyzed. Out of these, 608 received postmastectomy radiotherapy and 80 patients were not given any radiation therapy. At a median follow-up of 67 months, the outcomes studied were locoregional recurrence (LRR), distant metastases, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses.

RESULTS

The frequency of LRR with or without distant metastases was 8.5%, and distant metastases was seen in 18.7% of patients. On univariate analyses, factors affecting LRR were age < 40 years (0.019), tumor stage ( P = 0.001 ), grade ( P = 0.027 ), pathological nodal status ( P ), deep resection plane (0.041), ER/PR status ( P = 0.032 ) and postmastectomy radiation therapy (PMRT) ( P ). DFS rate was 69% at 5 years. Factors affecting distant metastases were age < 40 years (0.005), tumor stage ( P ), grade ( P = 0.0007 ), pathological nodal status ( P ), extra capsular extension (ECE) ( P = 0.002 ), hormonal therapy ( P ) and PMRT ( P ). The OS rate was 81% at 5 years. Factors affecting OS were tumor stage ( P ), grade ( P = 0.0001 ), pathological nodal status ( P ), ECE ( P = 0.002 ) ER/PR status ( P = 0.008 ), hormonal therapy ( P = 0.001 ) and PMRT ( P = 0.004 ). On multivariate analysis, factors affecting LRR were age ( P = 0.001 ), tumor stage ( P = 0.021 ), deep resection plane (0.003), ECE ( P = 0.022 ) and PMRT ( P = 0.047 ). Factors affecting distant metastases were menopause ( P = 0.044 ), grade ( P = 0.012 ), ECE ( P = 0.017 ) and PMRT ( P = 0.012 ). Factors affecting OS were menopausal status ( P = 0.017 ), tumor stage ( P = 0.029 ), pathological nodal status ( P = 0.011 ) and PMRT ( P = 0.002 ).

CONCLUSION

PMRT improves LRR as well as OS in patients with carcinoma breast. Other factors of prognostic importance were menopausal status, tumor stage and pathological nodal status.

Impact of changing trends of treatment on outcome of cerebral gliosarcoma: A tertiary care centre experience

AIM

To assess clinicopathological features and outcomes in patients of primary gliosarcoma with changing trends of treatment.

MATERIALS AND METHODS

Medical records were reviewed and data collected on primary gliosarcoma over a 5-year period (2009-2013) from the departmental case files.

RESULTS

A total 27 patients were included in this study. The median age of presentation was 54 years. There was a slight male preponderance, with male to female ratio of 1.25:1. The most common location of the tumor was temporal lobe (44.4%). Gross total resection was possible in 19 cases, near total excision was done in five cases, and only partial excision with decompression in three cases. Of the 27 patients, 80.8% patients received post-operative radical external beam radiotherapy of 60 Gy/30#/6 weeks. Concurrent and adjuvant temozolomide was used in 42.3% cases, depending on affordability and tolerance. Median overall survival was 9 months. On subgroup analysis, median overall survival in the radiotherapy plus temozolomide group was 10 months as compared to 9 months in the radiotherapy alone group; however, this was not statistically significant.(P = 0.244).

CONCLUSION

Treating Gliosarcoma is a major therapeutic challenge for a clinician because of its poor prognosis, aggressive clinical behavior, rarity, and limited clinical experience. With surgery and concurrent chemoradiation, we were able to achieve a median overall survival of 9 months. Addition of temozolomide has shown a better trend in survival though it is not statistically significant.

Postmastectomy internal mammary node radiation in women with breast cancer: a long-term follow-up study

Background

To observe the impact of internal mammary node irradiation (IMNI) on disease-free survival (DFS) and overall survival (OS) in postmastectomy women with breast cancer.

Materials and methods

Between 1978 and 1996, 153 women with stage II–III breast cancer were treated with postmastectomy radiation therapy (RT) with IMNI. Their clinical, pathological and treatment characteristics were matched with 166 patients without IMNI. The RT dose was 35 Gy to the chest wall and 40 Gy to the supraclavicular fossa and IMN in 15 fractions over 3 weeks with photons. All patients were planned with two-dimensional technique. Adjuvant chemotherapy was administered to 41% and endocrine therapy to 52% of the patients. Symptomatic patients were further assessed for late pulmonary and late cardiac effects.

Results

The median follow-up period was 203 months (range, 182–224), and the median age was 44 years (range 20–73 years). The IMNI group had significantly more right-sided and inner/central quadrant tumours. Other characteristics were comparable between both the groups. DFS at 15 years with and without IMNI was 64 and 49%, respectively (p=0·0001). On multivariate analysis, IMNI was an independent, positive predictor of DFS [hazard ratio (HR), 2·89;p=0·0001]. Benefit of IMNI on DFS was more apparent in inner/central tumours [HR, 1·48; 95% confidence interval (CI), 1·02–2·88], N2–N3 patients (HR, 1·44; 95% CI, 1·09–2·10) and in those who received chemotherapy (HR, 1·70; 95% CI, 1·07–2·71). OS at 15 years with and without IMNI was 68 and 54%, respectively (p=0·0001). Late pulmonary toxicity was 1·5 versus 1% with and without IMNI, respectively. Late cardiac toxicity was 2·6 versus 1·8% with and without IMNI, respectively.

Conclusions

IMNI significantly improved DFS and OS in postmastectomy breast cancer patients. Benefit of IMNI was seen in patients with central/inner tumours and N2–N3 disease. Late cardiopulmonary toxicities were comparable between the two groups.

Carcinoma lung presenting with choroidal metastasis as initial presentation: a rarity

Diminished vision due to choroidal metastasis as the primary symptom of lung cancer is very uncommon. Here, we report such a presentation in a 54-year-old male patient of small cell lung cancer. The outcome is usually dismal with this kind of presentation. The patient received systemic chemotherapy as well as intravitreal bevacizumab but with no improvement in vision. The patient had been given external beam radiotherapy and showed subjective improvement in his ocular symptoms.

Significance of serum vascular endothelial growth factor and cancer antigen 15.3 in patients with triple negative breast cancer

Background

A pilot study was undertaken to find significance of vascular endothelial growth factor (VEGF) and cancer antigen (CA 15.3) in breast cancer patients.

Materials and methods

Total 70 patients with breast cancer were divided into triple negative breast cancer (TNBC) and non-TNBC depending on oestrogen receptors, progesterone receptors or HER-2/neu receptors status. Serum CA 15.3 and VEGF levels were evaluated with enzyme-linked immunosorbent assay at the time of diagnosis and were correlated with age, tumour size and stage of the disease in both the groups. Spearman's test was used to find the correlation.

Results

VEGF levels were found to be >400 pg/ml in 27 patients, 19 (54·33%) of them were TNBC and only 8 (22·87%) non-TNBC. Mean values of the VEGF were, 784·34 pg/ml in TNBC and 334·60 pg/ml non-TNBC patients, respectively. CA 15.3 level was found to be higher in non-TNBC group (60·72 U/ml) than in TNBC group (45·24 U/ml). In all patients significant correlation was found between serum CA 15.3 level and tumour size and stage of the disease. In non-TNBC patients significant correlation was seen between CA 15.3 values and stage of the disease, but VEGF had no correlation with any of the disease parameters. In TNBC patients, there was no correlation between CA 15.3 level and any of the disease parameters but VEGF showed a significant correlation with both tumour size and stage of the disease.

Conclusion

Expression profile of VEGF was high in TNBC than non-TNBC patients. VEGF serves to be a better biomarker as compared with CA 15.3 in TNBC patients.

Paraneoplastic leukocytoclastic vasculitis in chronic lymphoid leukemia

A 50-year-old female who was a known case of chronic lymphoid leukemia (CLL) developed ecchymoses, purpuric spots with papules, some nodules (1-3 mm) and crusts all over the body associated with severe burning and itching along with exaggeration of CLL. The lesions were more prominent on lower limbs and face. Skin biopsy was reported as leukocytoclastic vasculitis. These lesions regressed after treatment with leukeran and glucocorticoids.

Post-mastectomy radiation beyond chest wall in patients with N1 breast cancer: is there a benefit?

INTRODUCTION

Nodal stage is the most important prognostic factor and one of the indicators for loco-regional radiation in patients with breast cancer. N1 (patients with 1-3 lymph node metastases in axilla) nodal stage is a controversial area as far as axillary and supraclavicular fossa (SCF) irradiation is concerned. We conducted a retrospective analysis at our institute to assess the impact of post-mastectomy radiotherapy (PMRT) beyond chest wall (CW) in N1- nodal stage breast cancer patients.

MATERIALS AND METHODS

Since January 2004 to December 2007, 293 post-mastectomy patients with N1 nodal stage breast cancer were analyzed for patient-related characteristics such as age, menopausal status, pathological stage/tumour size, tumour location, histology, oestrogen/progesterone receptor status, histological grade, extra capsular extension, lymph vascular invasion and treatment-related factors, PMRT and systemic therapy. Outcome studied were locoregional recurrence rate (LRR), disease free survival (DFS) and overall survival (OS).

RESULTS

At a median follow up of 55m, 260 patients received radiotherapy; 212 to CW+SCF, 48 to the CW only; and 33 patients did not receive radiotherapy. LRR was 5% in patients who received radiotherapy to CW+SCF and 8% in CW only (P = 0.34). There was no difference in the DFS between the two groups. OS at 5 year was 88% in CW+SCF group and 76% in CW only group respectively (P < 0.001).

CONCLUSION

In N1 nodal stage patients with breast cancer LRR was not significantly different after radiation to CW+SCF or to the CW only but OS was significantly better.

Outcome of neoadjuvant chemotherapy in locally advanced breast cancer: A tertiary care centre experience

BACKGROUND

Introduction of neoadjuvant chemotherapy (NACT) has dramatically changed the management of locally advanced breast cancer (LABC). However, very few randomized trials of NACT have been carried out specifically in LABC patients in our country. In this retrospective analysis, we presented our experience with NACT in LABC patients.

MATERIALS AND METHODS

Medical records of 148 patients of stage III LABC patients treated with NACT, followed by surgery and radiotherapy from January 2006 to December 2010 were reviewed. Clinical and pathological responses to different chemotherapy regimens were assessed according to World Health Organization criteria. Various factors influencing response to NACT and clinical outcome were identified and analyzed.

RESULTS

A total of 90 (60.8%) patients received anthracycline-based chemotherapy and 52 (35.1%) patients received mixed anthracycline and taxane-based chemotherapy.119 patients (80.4%) responded to NACT either in the form of complete or partial response (PR). Complete response was seen in 27 (18.2%) patients and 92 (62.2%) patients showed PR after NACT. Pathological complete response was seen in 24 (16.2%) patients-. At a median follow-up period of 44 months 36 patients (24.3%) developed relapse of which six patients developed locoregional recurrence, while 28 (18.9%) patients developed distant metastasis. Nodal status, response to chemotherapy, pathological tumor size <3 cm and extracapsular extension (ECE) came out to be important prognostic factors in this study.

CONCLUSION

Neoadjuvant chemotherapy is a reasonable alternative to upfront surgery in the management of LABC. Clinicopathological variables such as nodal status, response to chemotherapy, pathological tumor size and presence of ECE had significant impact on disease free survival.

Gynecological Cancer as a Second Malignancy in Patients With Breast Cancer

PURPOSE

The aim of this study was to determine the incidence and risk factors for gynecological cancer as second malignancy (SM) after treatment of breast cancer (BC).

METHODS AND MATERIALS

Between January 1985 and December 2007, a total of 2756 patients with BC were analyzed for gynecological cancers as an SM. Analysis was carried out for patient-, disease-, and treatment-related characteristics. The Cox proportional hazards regression model was used to estimate the relative risk of gynecologic malignancies.

RESULTS

The median age at BC diagnosis was 49 years and median follow-up of 14 years. In total, 25 cases of gynecological cancer were noted with an incidence of 0.9%. We observed 9 ovarian and endometrium (0.3%) as well as 7 uterine cervix (0.25%) cancers. Family history of BC was the most significant risk factor for SM (relative risk, 7.4; 95% confidence interval, 3.03-18.28; P<0.001). Women with a family history of BC had a higher incidence of endometrial (12%) and ovarian (16%) cancer compared with those who have no family history (0.1%, P = 0.003). Statistically significant higher incidence of endometrial cancer was seen in patients undergoing hormonal therapy (0.4%) as compared with those who are not undergoing hormonal therapy (0.1%, P = 0.001). Most of the endometrial (88.9%) and cervical (71%) cancers were detected at an early stage but ovarian cancers (66.6%) in advanced stage. Chemotherapy and radiotherapy did not increase the risk of gynecological SM.

CONCLUSIONS

Women with BC are at risk of developing a second primary gynecological malignancy particularly of endometrium and ovary. Family history of BC was a high risk factor for gynecologic SM. These patients should be followed up for its early detection.