Dramatic responses to gefitinib when used as front line therapy in two cases of metastatic lung adenocarcinoma with poor performance status

A 54-year-old man, a non-smoker, suffering from metastatic lung adenocarcinoma presented with extensive bilateral pulmonary infiltrates. He was dyspneic at rest. Performance status (PS) was 4. Institution of gefitinib resulted in relief from dyspnea within two weeks. Positron emission tomography done after 10 months revealed only a 2 cm residual lesion. However, the patient stopped therapy on his own and died two months later. An 80-year-old female, a non smoker, presented with metastatic lung adenocarcinoma and right sided pleural effusion. Her PS was 4. She was started on gefitinib. Within four weeks, she showed marked improvement. At six months, she was radiologically documented to be in partial remission. She continues to be asymptomatic at one year follow-up. These are the first reports of dramatic responses to gefitinib when used as front-line therapy in patients with poor performance status from India.

Profile of infections and outcome in high-risk febrile neutropenia: experience from a tertiary care cancer center in India

Objective of the present study was to describe the profile of infections in febrile neutropenia (FN) in acute leukemia and hematopoietic stem cell transplant (HSCT) with emphasis on response to therapy and outcome. In a prospective, observational single-institutional study, consecutive episodes of high-risk FN were enrolled over a 1½-year period. Uniform antibiotic policy and response criteria were used. Of the 200 episodes enrolled, acute leukemia induction comprised 40.5%, consolidation with high-dose cytarabine 22.5%, HSCT 29% (auto-HSCT 84%), and others 8% of the episodes, respectively. Microbiologically documented infections comprised 30% episodes, while bacteremia was documented in 26% episodes. Gram-negative isolates were more common (55.7%). Cefoperazone-sulbactam had the highest in vitro efficacy against Gram-negative rods. Carbapenem resistance was most prevalent among Acinetobacter spp. (80%) and Pseudomonas aeruginosa (50%). All Gram-positive cocci other than enterococci were susceptible to vancomycin, while 2/8 enterococci were resistant to it. Cefoperazone-sulbactam and amikacin were used as first-line antibiotics. Overall mortality was 8%. On multivariate analysis, mortality was associated with a nadir leukocyte count < 200/μl and an abnormal chest radiograph. Among high-risk FN patients, inspite of a high-level of resistance to antibiotics, a frontline regime containing cefoperazone-sulbactam could restrict the use of imipenem and resulted in an acceptable mortality of 8%.

Response assessment of patients with chronic myeloid leukemia receiving imatinib mesylate (Glivec) therapy: experience from a single center in a developing country

Imatinib mesylate, a targeted inhibitor of BCR-ABL tyrosine kinase, is a standard of care for chronic myeloid leukemia (CML). There are few publications on responses of patients with CML from the Indian subcontinent. This study analyzed the response rate, progression-free survival (PFS), overall survival (OS), and toxicities in patients with CML given imatinib. Analysis included patients with CML who received imatinib under the GIPAP program at our institution from January 2002 to December 2008. Standard criteria for hematological and cytogenetic responses were used. There were 400 patients, with a median follow-up of 47 months. One hundred and seventy received prior non-imatinib therapy and 230 patients received imatinib upfront. Ninety-five percent of patients achieved complete hematological response. The cumulative best rate of major cytogenetic response was 72%, with 53% complete cytogenetic response and 19% partial cytogenetic response. The estimated PFS and OS at median follow-up for the whole group was 76% and 94%, respectively. Differences in PFS and OS in prior non-imatinib and upfront imatinib groups were not statistically significant. However, better PFS and OS were seen in the upfront imatinib group. Imatinib was well tolerated in our study.

Best supportive care compared with chemotherapy for unresectable gall bladder cancer: a randomized controlled study

PURPOSE

We designed this study to evaluate efficacy of modified gemcitabine and oxaliplatin (mGEMOX) over best supportive care (BSC) or fluorouracil (FU) and folinic acid (FA) in unresectable gall bladder cancer (GBC).

PATIENTS AND METHODS

Patients with unresectable GBC were enrolled for single center randomized study. Arm A, BSC; arm B, FU 425 mg/m(2) and FA 20 mg/m(2) intravenous (IV) bolus weekly for 30 weeks (FUFA); arm C, gemcitabine 900 mg/m(2) and oxaliplatin 80 mg/m(2) IV infusion on days 1 and 8 every 3 weeks for maximum of six cycles. Eighty-one patients were randomly assigned, arms A (n = 27), B (n = 28), and C (n = 26).

RESULTS

Complete response plus partial response in the three groups was 0 (0%), four (14.3%), and eight (30.8%) respectively (P < .001). Two patients in the mGEMOX arm and one patient in the FUFA arm underwent curative resection after chemotherapy. One patient in the mGEMOX arm had complete pathologic response. Median overall survival (OS) was 4.5, 4.6, and 9.5 months for the BSC, FUFA, and mGEMOX arms (P = .039), respectively. Progression-free survival (PFS) was 2.8, 3.5, and 8.5 months for the three groups (P < .001). There was no difference in grade 3/4 toxicities in the chemotherapy arms except transaminitis, which was more prevalent in mGEMOX arm (P = .04). Two patients in the FUFA arm and 10 patients in the mGEMOX arm had grade 3 or 4 myelosuppression. Two patients in the mGEMOX group had neutropenic fever that resolved with antibiotics.

CONCLUSION

This randomized controlled trial confirmed the efficacy of chemotherapy (mGEMOX) compared with BSC and FUFA in improving OS and PFS in unresectable GBC.

HIV-associated non-Hodgkin's lymphoma: experience from a regional cancer center

AIMS

To analyze clinical features and survival in HIV-associated non-Hodgkin lymphoma (NHL) cases registered at Dr BRA Institute Rotary Cancer Hospital of AIIMS, New Delhi.

MATERIALS AND METHODS

We have retrospectively reviewed records of NHL patients registered, from January 2003 to July 2007 to analyze HIV-associated NHL.

RESULTS

Seven cases of HIV-associated NHL cases were identified. Age range was 14-56 years. Five were males. Baseline performance status (ECOG-PS) was >I in 6. Mean LDH was 409 U/L. Mean hemoglobin was 10.5 g% and mean CD4 count was 243/mm3 (range 18-454). Three cases had nodal lymphoma and four had extra nodal lymphoma. No primary CNS (PCNSL) lymphoma was seen. All patients were of advanced stages and of intermediate to high-risk group based on international prognostic index (IPI). Six cases had high-grade NHL. None had CNS involvement. Five had B symptoms. HIV infection was diagnosed as part of NHL work-up in five patients. All patients received HAART. All were planned for chemotherapy with CNS prophylaxis. Protocols used were CVP, CHOP, R-CHOP or MCP-842. One patient received IFRT.

RESPONSE

One patient achieved complete response (CR) and continues to be disease free, with 4.5 years of follow-up. Three cases achieved partial response (PR) and 2 had progressive disease (PD). Currently, three patients are on follow-up.

CONCLUSIONS

These NHL are of higher grade and advanced stage. Response and tolerance to chemotherapy is poor. Appropriate supportive care and CNS prophylaxis might improve outcome. We need to improve epidemiological data collection system in this part of world. With HAART, the goal of therapy is durable CR rather than palliation.

T cell-prolymphocytic leukemia detected in a patient of breast cancer at the time of recurrence: a case report

Introduction

Therapy related second malignancy of the hematological system is small but real risk after adjuvant chemotherapy for breast cancer. It includes acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS); however T-cell prolymphocytic leukemia (T-PLL) has not been described earlier in relation to breast cancer and its therapy. T-PLL is a rare chronic T-cell lymphoproliferative disease with a mature post-thymic T-cell immunophenotype and aggressive clinical course.

Case presentation

A 45 year old Indian female of Nordic origin presented 5 years back with a lump in the right breast and the axilla. She underwent modified radical mastectomy. Histophotomicrograph of the excised breast lesion showed a 2.1 cm duct carcinoma, positive for ER and PR with 1 out of 25 lymph nodes positive for metastasis. She received 6 cycles of chemotherapy with cyclophosphamide, epirubicin, and 5-fluorouracil. This was followed by tamoxifen 20 mg per day for five years. She was doing well on follow up until the completion of fifth year of her disease, when she presented with complaints of mild fever and weakness. Examination revealed generalized lymph node enlargement along with hepatomegaly.

Hemogram showed mild anemia, normal platelet count and a leukocyte count of 1.2 × 10¹¹/L. Peripheral blood examination revealed medium sized lymphoid cells, constituting almost 75% of total nucleated cell population. Immunophenotying, established a diagnosis of post thymic T-cell prolymphocytic leukemia. Contrast-enhanced computed tomography of the chest and abdomen was done which revealed an anterior mediastinal mass with destruction of sternum along with multiple small nodular shadows in bilateral lung fields suggestive of lung metastasis. Fine needle aspiration cytology of the mass showed atypical ductal cells with nuclear pleomorphism, which were positive for ER, PR and Her2neu protein. This confirmed a co-existent metastatic breast carcinoma. She was started on chemotherapy for T-PLL along with hormonal therapy with aromatase inhibitor. Unfortunately, both her malignancies progressed after an initial stable disease of two months.

Conclusion

Our case describes the potential of breast chemotherapy to cause grave second hematological malignancies of the T-cell lymphoid lineage, not described earlier. Such events highlight the importance to identify those patients of breast cancer in whom chemotherapy can safely be avoided.

Cancer incidences in rural Delhi--2004-05

There are no data available on cancer incidence pattern in rural Delhi. This is the first report on cancer incidence among Delhi Rural population during 2004-05 which gives the first hand information on cancer incidence. The data for this report has been collected by Delhi Population based cancer registry. The sources for cancer registration are more than 162 Government Hospitals/centers and 250 private hospitals and nursing homes. A total of 594 cancer cases with 317 males and 277 females were registered during the period 1st January 2004 to 31st December 2005. The age adjusted (world population) incidence rates for all sites were 55.2 per 100,000 for males and 47.7 per 100,000 for females. The leading sites of cancer among Delhi Rural males was oral cavity (ASR: 8.0 per 100000) followed by lung (ASR: 6.5), larynx (ASR: 4.0) and bladder (ASR: 4.1). In females cervix uteri (ASR: 10.3 per 100,000) was the most common site of cancer followed by breast (ASR: 7.8), gallbladder (ASR: 3.5) and ovary (ASR: 3.3). The overall incidence rates of cancer in Delhi Rural were comparatively very less than Delhi Urban. A statistically significant difference was also found between Delhi Rural and Delhi Urban in incidence rates (ASR) for first four common sites. The rates in Delhi Rural are also comparatively lower than other rural registries situated in India.

Characteristics and pattern of mortality in cancer patients at a tertiary care oncology center: report of 259 cases

BACKGROUND

Little is known about mortality statistics of hospitalised cancer patients from developing countries. This paper describes the distribution of causes of death in various malignancies, status of malignancy at the time of death, type and intent of therapy received by the cancer patient prior to death and nature of infections in terminal cancer patients who died in hospital. We also aimed to study discrepancies in mortality reporting in terms of death certificate at our center and tried to analyse possible causes.

RESULTS

Data for 259 consecutive deaths in hospitalized cancer patients in a calendar year were analysed. Of all these, 147 (57%) were cases of solid tumors, 107 (41%) were cases of hematological malignancies and 5 (2%) were other or undiagnosed cases. Median duration of hospital stay prior to death was 7 (1-106) days. Sepsis/multi organ dysfunction syndrome (MODS) was commonest immediate cause of death 118/259 (45.2%) followed by progressive malignancy in 64/259 (24.7%) cases. Only 13/267 (5%) patients died with controlled cancer. Some 184 (71.3%) deaths occurred within 90 days of any form of anticancer treatment of which more than three fourths (77.2%) occurred after chemotherapy. Among these chemotherapy related deaths, 63 were febrile neutropenic deaths, with the commonest site of infection in the lungs, and positive blood culture was found in 18 (28%) cases. There were discrepancies in information derived from death certificates and from case records in 84 (32%) cases. Most of these were due to the use of ambiguous terms like cardio-respiratory arrest as a cause of death in the death certificate.

CONCLUSION

It is important to audit mortality data on a regular basis as this can provide valuable insight into hospital practice and may help to identify preventable causes of mortality. Mortality record keeping is another important aspect as variable practices in this area may have implications for cancer mortality reporting and this may ultimately lead to erroneous cancer epidemiology.

Expression of CD13/aminopeptidase N in precursor B-cell leukemia: role in growth regulation of B cells

Expression of cell surface CD13 in acute B-cell leukemia (ALL-B) is often viewed, as an aberrant expression of a myeloid lineage marker. Here, we attempted to study the stage specific expression of CD13 on ALL-B blasts and understand its role in leukemogenesis as pertaining to stage of B-cell ontogeny. A total of 355 cases of different hematological malignancies were diagnosed by immunophenotyping. Among 68 cases of early B-cell ALL, 22 cases with distinct immunophenotype was identified as immature B-cell ALL. Blasts from these ALL-B patients demonstrated prominent expression of CD10, CD19, CD22, but neither cytoplasmic nor surface IgM receptors. This strongly indicates leukemogenesis at an early stage of B-cell development. We also identified, the existence of a subpopulation of cells with remarkably similar phenotype in non-leukemic marrow from healthy subjects (expressing CD10, CD19, CD22, CD24, Tdt together with the co-expression of CD13). This sub-population of B cells concomitantly expressing CD13 appeared to be a highly proliferating group. By blocking their cell surface CD13 in leukemic blasts with monoclonal antibody we were able to inhibit their proliferation. We hypothesized that neoplastic transformation at this stage may be facilitated by CD13. CD13 may thus be an important target for novel molecular therapy of early stage acute B-cell leukemia.