Mediastinal Gray Zone Lymphoma

Aim. To identify aggressively behaving classical Hodgkin lymphoma (CHL) of mediastinum and primary mediastinal B-cell lymphoma (PMBCL) and to classify them as mediastinal gray zone lymphoma(MGZL) and to define a minimum immunopanel for the diagnosis of MGZL. Materials and Methods. Ninety-two mediastinal B-cell lymphomas were reviewed with a wide immunopanel and were classified as CHL, PMBCL, or MGZL. CHL with an expression of 3 or 4 transcription factors performed worse, and hence the CHL with ≥3 transcription factors were classified as MGZL-CHL. In PMBCL, the cases with a weak or negative CD20 and positive CD15 as well as those cases showing cyclin E positivity with a negative or focal LCA and any one of the transcription factors were classified as MGZL-PMBCL. Results. The MGZL cases expanded from 9 to 28 cases after using an extended immunopanel. CHL and PMBCL had a disease-free survival rate of 86.8% and 69.2% and an overall survival rate of 97.4% and 80.8%, respectively. MGZL-CHL and MGZL-PMBCL had a disease-free survival rate of 33% and 40% and an overall survival rate of 66.7% and 60%, respectively. Conclusion. Thus, the MGZL may be a wider category than we think and hence the use of a wide immunopanel is recommended to identify the aggressively behaving mediastinal B-cell lymphomas.

Toward the Cure of All Children With Cancer Through Collaborative Efforts: Pediatric Oncology As a Global Challenge

Advances in the treatment of childhood cancers have resulted in part from the development of national and international collaborative initiatives that have defined biologic determinants and generated risk-adapted therapies that maximize cure while minimizing acute and long-term effects. Currently, more than 80% of children with cancer who are treated with modern multidisciplinary treatments in developed countries are cured; however, of the approximately 160,000 children and adolescents who are diagnosed with cancer every year worldwide, 80% live in low- and middle-income countries (LMICs), where access to quality care is limited and chances of cure are low. In addition, the disease burden is not fully known because of the lack of population-based cancer registries in low-resource countries. Regional and ethnic variations in the incidence of the different childhood cancers suggest unique interactions between genetic and environmental factors that could provide opportunities for etiologic research. Regional collaborative initiatives have been developed in Central and South America and the Caribbean, Africa, the Middle East, Asia, and Oceania. These initiatives integrate regional capacity building, education of health care providers, implementation of intensity-graduated treatments, and establishment of research programs that are adjusted to local capacity and local needs. Together, the existing consortia and regional networks operating in LMICs have the potential to reach out to almost 60% of all children with cancer worldwide. In summary, childhood cancer burden has been shifted toward LMICs and, for that reason, global initiatives directed at pediatric cancer care and control are needed. Regional networks aiming to build capacity while incorporating research on epidemiology, health services, and outcomes should be supported.

Is there a role for metronomic induction (and maintenance) therapy in elderly patients with acute myeloid leukemia? A literature review

Acute myeloid leukemia (AML) in older adults differs biologically and clinically from that in younger patients and is characterized by adverse chromosomal abnormalities, stronger intrinsic resistance, and lower tolerance to chemotherapy. In patients over age 60 with AML, cure rates are under 10% despite intensive chemotherapy, and most of them die within a year of diagnosis. Over the last decade, metronomic chemotherapy has emerged as a potential strategy to control advanced/refractory cancer. Here, we report a case of a 68-year-old gentleman having AML with high-risk cytogenetic features, who achieved complete remission on our oral metronomic PrET (PrET: Prednisolone, etoposide, thioguanine) protocol on an outpatient basis. He was later treated with standard high-dose (HD) cytosine arabinoside (Ara-C) consolidation followed by maintenance with etoposide, thioguanine, and sodium valproate. Presently, the patient is nearly 35 months since diagnosis and 21 months off treatment. This case report and review highlights that the combination of oral low-intensity metronomic therapy, followed by standard HD consolidation therapy and metronomic maintenance therapy may be well tolerated by elderly patients especially with less proliferative, high (cytogenetic)-risk AML who are otherwise deemed to be unfit for intensive intravenous induction chemotherapy regimens. References for this review were identified through searches of Pubmed for recent publications on the subject as well as searches of the files of the authors themselves. The final list was generated on the basis of originality and relevance to this review.

Targeted therapy with propranolol and metronomic chemotherapy combination: sustained complete response of a relapsing metastatic angiosarcoma

We report here a case of a 69-year-old woman with a relapsing metastatic angiosarcoma treated with a combination of metronomic chemotherapy and propranolol. The beta blockers were added since the tumour was positive for betaadrenergic receptor. A complete response was quickly obtained and lasted for 20 months.

With this case, the combination of metronomic chemotherapy and propranolol in angiosarcoma warrants additional studies and illustrates the potential of metronomics to generate innovative yet inexpensive targeted therapies for both high-income and low-/middle-income countries.

A prospective randomized phase II study comparing metronomic chemotherapy with chemotherapy (single agent cisplatin), in patients with metastatic, relapsed or inoperable squamous cell carcinoma of head and neck

BACKGROUND

Cetuximab based treatment is the recommended chemotherapy for head and neck squamous cell cancers in the palliative setting. However, due to financial constraints, intravenous (IV) chemotherapy without cetuximab is commonly used in lesser developed countries. We believe that oral metronomic chemotherapy may be safer and more effective in this setting.

METHODS

We conducted an open label, superiority, parallel design, randomized phase II trial comparing oral MCT [daily celecoxib (200mg twice daily) and weekly methotrexate (15mg/m(2))] to intravenous single agent cisplatin (IP) (75mg/m(2)) given 3 weekly. Eligible patients had head and neck cancers requiring palliative chemotherapy with ECOG PS 0-2 and adequate organ functions who could not afford cetuximab. The primary end point was progression-free survival.

RESULTS

110 Patients were recruited between July 2011 to May 2013, 57 randomized to the MCT arm and 53 to the IP arm. Patients in the MCT arm had significantly longer PFS (median 101 days, 95% CI: 58.2-143.7 days) compared to the IP arm (median 66 days, 95% CI; 55.8-76.1 days) (p=0.014). The overall survival (OS) was also increased significantly in the MCT arm (median 249 days, 95% CI: 222.5-275.5 days) compared to the IP arm (median 152 days, 95% CI: 104.2-199.8 days) (p=0.02). There were fewer grade 3/4 adverse effects with MCT, which was not significant. (18.9% vs. 31.4%, P=0.14).

CONCLUSION

Oral metronomic chemotherapy has significantly better PFS and OS than single agent platinum in the palliative setting.

A simplified scoring system to document variant patterns in nodular lymphocyte predominant Hodgkin lymphoma

This study sought to quantify variant patterns in nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) using a three tier scoring system assessing five parameters, namely: (a) percentage of nodularity scored from 100 % to < 75%, (b) T cell rich areas (< 20% to > 50%), (c) type of nodules, (d) dendritic network, intact or lost, and (e) extranodular distribution of lymphocyte predominant cells (< 15% to > 50%), with final scores from 0 to 10. In the 72 patients assessed, the 5-year disease-free survival (DFS) in patients with score ≤ 6 was 92% vs. 20% in those with scores > 6. The 5-year overall survival was 100% in patients with scores ≤ 6 and 87% in those with scores > 6. In the multivariate Cox regression analysis, scores > 6 and stage impacted DFS. This scoring system was effective in stratifying patients with NLPHL with variant patterns and could be used for the management of patients.

Lessons from the Fourth Metronomic and Anti-angiogenic Therapy Meeting, 24-25 June 2014, Milan

The Fourth Metronomic and Anti-angiogenic Therapy Meeting was held in Milan 24–25 June 2014. The meeting was a true translational meeting where researchers and clinicians shared their results, experiences, and insights in order to continue gathering useful evidence on metronomic approaches. Several speakers emphasised that exact mechanisms of action, best timing, and optimal dosage are still not well understood and that the field would learn a lot from ancillary studies performed during the clinical trials of metronomic chemotherapies. From the pre-clinical side, new research findings indicate additional possible mechanisms of actions of metronomic schedule on the immune and blood vessel compartments of the tumour micro-environment. New clinical results of metronomic chemotherapy were presented in particular in paediatric cancers [especially neuroblastoma and central nervous system (CNS) tumours], in angiosarcoma (together with beta-blockers), in hepatocellular carcinoma, in prostate cancer, and in breast cancer. The use of repurposed drugs such as metformin, celecoxib, or valproic acid in the metronomic regimen was reported and highlighted the potential of other candidate drugs to be repurposed. The clinical experiences from low- and middle-income countries with affordable regimens gave very encouraging results which will allow more patients to be effectively treated in economies where new drugs are not accessible. Looking at the impact of metronomic approaches that have been shown to be effective, it was admitted that those approaches were rarely used in clinical practice, in part because of the absence of commercial interest for companies. However, performing well-designed clinical trials of metronomic and repurposing approaches demonstrating substantial improvement, especially in populations with the greatest unmet needs, may be an easier solution than addressing the financial issue. Metronomics should always be seen as a chance to come up with new innovative affordable approaches and not as a cheap rescue strategy.

Response assessment in metronomic chemotherapy: RECIST or PERCIST?

INTRODUCTION

Metronomic chemotherapy (MC) is a novel therapeutic variation for resistant cancers, wherein chemotherapeutic drugs are administrated in low doses with no prolonged drug-free break. It lessens the level of toxicity, is better tolerated and enhances the quality of life. This retrospective analysis was undertaken to evaluate whether anatomical (computed tomography [CT]) or functional (positron emission tomography [PET]) imaging be used for response assessment in patients on MC.

MATERIALS AND METHODS

A total of 16 males and 27 females with age range of 12-83 years on MC who underwent PET/CT were assessed by new response evaluation criteria in solid tumors (RECIST 1.1) and PET response criteria in solid tumors (PERCIST 1.0).

RESULTS

Concordance between RECIST 1.1 and PERCIST was seen in 32 (75%) patients. There was discordance in 11 (25%) patients. In patients with discordance, the results were confirmed by follow-up imaging. PET upstaged the disease in 81% of patients (9/11) and down-staged the disease in 19% of patients (2/11).

CONCLUSIONS

Metabolic response accurately identified the disease status as assessed by clinical or imaging follow-up. Alteration in morphology takes time to manifest, which is demonstrated by CT or magnetic resonance; whereas in MC which brings about tumor dormancy, assessing metabolic response by PET would be more appropriate. MC is usually given in palliative setting but in few cases complete metabolic response was demonstrated in our study. In such a scenario this form of treatment has the potential to become an adjunct mode of treatment in some tumors. This needs to be evaluated with larger, homogenous patient population in a prospective mode.

Has the time come for metronomics in low-income and middle-income countries?

In 2008, 72% of cancer deaths occurred in low-income and middle-income countries, where, although there is a lower incidence of cancer than in high-income countries, survival rates are also low. Many patients are sent home to die, and an even larger number of patients do not have access to treatment facilities. New constraint-adapted therapeutic strategies are therefore urgently needed. Metronomic chemotherapy--the chronic administration of chemotherapy at low, minimally toxic doses on a frequent schedule of administration, with no prolonged drug-free breaks--has recently emerged as a potential strategy to control advanced or refractory cancer and represents an alternative for patients with cancer living in developing countries. This low-cost, well-tolerated, and easy to access strategy is an attractive therapeutic option in resource-limited countries. Moreover, combined with drug repositioning, additional anticancer effects can be achieved, ultimately resulting in improved cancer control while maintaining minimum cost of treatment. In this Personal View, we will briefly review the rationale behind the combination of metronomic chemotherapy and drug repositioning-an approach we term metronomics. We assess the clinical experience obtained with this kind of anticancer treatment and describe potential new developments in countries with limited resources. We also highlight the need for adapted clinical study endpoints and innovative models of collaboration between for-profit and non-profit organisations, to address the growing problem of cancer in resource-limited countries.

Predicting complications of chemotherapy-induced febrile neutropenia: A single-center experience

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Background: Identifying the parameters associated with increased complications would help to formulate a cost-effective and rational therapy in patients with chemotherapy induced febrile neutropenia. Methods: We prospectively collected data from January 2007-December 2011 of consecutive episodes of neutropenic fever at our centre. Clinical features, laboratory characteristics and MASCC score were analysed to identify patients at higher risk for developing complications. Complications were defined as either of the following event: failure of first line antibiotics, organ failure, delay in next cycle of chemotherapy, inpatient admission and death. Results: Three hundred and eighty-eight febrile neutropenia (FN) episodes in 373 patients were included, 256 episodes of FN in hematolymphoid malignancies and 132 episodes of FN in solid tumours. The median age was 31 years (11-76 years). Two hundred and forty-four (65.4%) patients were male. One hundred forty-nine patients (39.94%) had FN during previous cycles, while primary GCSF prophylaxis was used for 205 (52.84%) cases. The median haemoglobin, nadir neutrophil count & median number of days with severe neutropenia (< 1X109/L) were 7.9 gm/dl, 0.04X109/L and 4 days respectively. A clinical focus of infection was present in 174 (44.8%) episodes, with gastrointestinal being the commonest in 70episodes (40.23%). High risk MASCC score (<21) was present in 156 episodes (40%). Complications were seen in 133(34%) instances. On Univariate analysis, age, type of malignancy, prophylactic growth factor use, clinical focus of infection, day of FN, MASCC score, nadir Hb and platelet count were significantly associated with complications. All predictive factors except age and nadir Hb could independently predict complication on multivariate analysis. Conclusions: Clinical and laboratory parameters in addition to MASCC score could help in identifying patients with FN who require hospitalisation and more intensive management strategies.

A phase II study of oral metronomic combination therapy in relapsed epithelial ovarian cancer

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Background: Etoposide (E), cyclophosphamide (C) and tamoxifen (T) have been used as single agents in relapsed epithelial ovarian cancer (EOC) patients. We tested a low dose, continuous, daily, oral metronomic regimen that combined these 3 agents. Methods: This single centre prospective study included patients of relapsed EOC with exposure to at least 2 prior lines of chemotherapy (CT) and at least partial as the best response to most recent regimen. Study regimen comprised daily oral administration of E (50 mg/m2) and C (50 mg/m2) for 21 of a 28 day cycle plus T (20 mg/m2, twice per day) continuously. The primary endpoint was serological (CA-125) progression-free survival (PFS) as per Rustin Criteria and secondary endpoints were radiological (RECIST) PFS, overall survival (OS), duration of response (DOR), response rates and toxicity. The data cut-off date was 15 Jan 2013. Results: 26 patients with a median age of 48 years were accrued, of whom 21 had received 2 prior lines of CT and 5 had received 3 lines. 25 patients who were evaluable for analysis received a median of 6 (1-19) cycles of metronomic regimen. The median delivered relative dose intensities of E, C and T were 0.71, 0.71 and 0.97 respectively. 13 (52%) patients needed dose reduction after a median of 3 (1-9) cycles. Most common grade 3 or 4 toxicities included anemia, neutropenia, febrile neutropenia, nausea, vomiting and diarrhea in 44%, 36%, 12%, 16%, 16% and 12% patients respectively. 19 (76%) patients had serological CR or PR with a median time to response (TTR) and DOR of 1.8 (0.83-2.96) and 7.0 (95% CI, 5.8-8.2) months respectively. 11 (45.8%) of the 24 evaluable patients achieved radiological CR or PR with median TTR and DOR of 3.7 (1.8-7.2) and 5.5 (95% CI, 3.9-7.2) months respectively. 17, 18 and 7 patients have respectively experienced serological progression, radiological progression and death at the time of analysis. The median serological PFS, radiological PFS and OS are 7.9 (95% CI 7.2-8.6), 7.97 (95% CI, 5.95-9.98) and 22.3 (95% CI, 17.4-27.3) months, respectively. Conclusions: The oral metronomic combination of E, C and T has substantial and durable activity in relapsed EOC and is worthy of further evaluation in a larger randomized study.

Pictorial essay: Acute neurological complications in children with acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the commonest childhood malignancy with high cure rates due to recent advances in central nervous system (CNS) prophylaxis. The disease per se, as well as the prophylactic therapy, predisposes the child to complications such as cerebrovascular events, infections, drug toxicities, etc. The purpose of this study is to highlight the pathophysiology and the imaging features (with appropriate examples) of these complications and to propose a diagnostic algorithm based on MRI. Interpreting these scans in the light of clinical inputs very often helps the radiologist reach an appropriate diagnosis and help treatment and management.

Results of autologous transplants for children from a tertiary cancer center in India

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Background: Autologous transplantation is a curative option for children with various malignancies. We report the results of our center with the aim of evaluating toxicities and prognostic factors that may influence decision making to use our limited resources judiciously. Methods: Forty-six patients diagnosed below 18 years from 1st April 1994- 28th February 2011 were included in this retrospective study. Twenty-four patients had lymphoma, 12- neuroblastoma and 10-others ( 5- acute leukemia, 4- Ewing sarcoma and 1 - rhabdomyosarcoma). Twenty-eight patients received peripheral blood stem cells, 12 – marrow and 6-both. Prognostic factors evaluated for overall survival (OS) and progression-free survival (PFS) were remission status at transplant, baseline and pre-transplant serum albumin, time interval between diagnosis and transplant, type of malignancy and number of lines of chemotherapy pre transplant. Results: Median age at diagnosis and transplant were 9 and 12 years respectively. Median baseline and pre transplant serum albumin were 3.6 and 3.9 g/dl. Median number of lines of chemotherapy was 2. Median time from diagnosis to transplant was 1.1 years. Incidence of grade 3 and 4 oral mucositis and diarrhea were 46% and 25% respectively. At the time of transplant, 45% were in complete remission (CR), 41% in partial remission (PR) and 13% in refractory state. Total Parenteral Nutrition (TPN) was used in 63% patients with median duration of 11 days. No patient developed sinusoidal obstruction syndrome.Median days to neutrophil and platelet engraftment were 11 and 15 days respectively. Neutropenic sepsis leading to death was seen in 17%. Median follow up was 1.5 years. At 2 years, the probability of OS and PFS were 39% and 35% for all patients while OS and PFS for lymphoma, neuroblastoma and others were 45% and 32%, 17% and 0% and 50% and 40% respectively. CR at transplant was the most important determinant of better OS (59 % vs 28%; p = 0.000004) and PFS (53% vs 8%; p = 0.0000018). Conclusions: CR at transplant is the most important prognostic factor. Patients with neuroblastoma have dismal outcome which requires reevaluation of transplant strategies for this group.

Second primary head and neck squamous cell cancers with aggressive behavior in patients with chronic myeloid leukaemia

Patients with chronic myeloid leukaemia (CML) are at considerable risk of developing second primary neoplasms. However, mucosal squamous cell cancers (SCCs) of the head and neck have not been reported. We review the data of 7 patients with mucosal SCC of the head and neck that presented as metachronous second primary tumours in patients with CML. All 7 patients were men (median age 48 years, range 31-67) (site:oral cavity n=6, hypopharynx n=1). The median interval between diagnosis of CML and head neck cancer was 6 years (range 2-15). Treatment was curative in 4 and palliative in 3. At median follow up of 14 months (range 2-44), 3 patients had died of head and neck cancer, 1 of CML, and 3 were alive and free of disease. Mucosal cancers of the head and neck can occur in long-term survivors of CML. They are aggressive and tend to recur.

Characterization of cryptic rearrangements, deletion, complex variants of PML, RARA in acute promyelocytic leukemia

Acute promyelocytic leukemia (APL) is characterized by a reciprocal translocation t(15;17)(q22;q21) leading to the disruption of Promyelocytic leukemia (PML) and Retionic Acid Receptor Alpha (RARA) followed by reciprocal PML–RARA fusion in 90% of the cases. Fluorescence in situ hybridization (FISH) has overcome the hurdles of unavailability of abnormal and/or lack of metaphase cells, and detection of cryptic, submicroscopic rearrangements. In the present study, besides diagnostic approach we sought to analyze these cases for identification and characterization of cryptic rearrangements, deletion variants and unknown RARA translocation variants by application of D-FISH and RARA break-apart probe strategy on interphase and metaphase cells in a large series of 200 cases of APL. Forty cases (20%) had atypical PML–RARA and/or RARA variants. D-FISH with PML/RARA probe helped identification of RARA insertion to PML. By application of D-FISH on metaphase cells, we documented that translocation of 15 to 17 leads to 17q deletion which results in loss of reciprocal fusion and/or residual RARA on der(17). Among the complex variants of t(15;17), PML–RARA fusion followed by residual RARA insertion closed to PML–RARA on der(15) was unique and unusual. FISH with break-apart RARA probe on metaphase cells was found to be a very efficient strategy to detect unknown RARA variant translocations like t(11;17)(q23;q21), t(11;17)(q13;q21) and t(2;17)(p21;q21). These findings proved that D-FISH and break-apart probe strategy has potential to detect primary as well as secondary additional aberrations of PML, RARA and other additional loci. The long-term clinical follow-up is essential to evaluate the clinical importance of these findings.

A study of pathologic risk factors in postchemoreduced, enucleated specimens of advanced retinoblastomas in a developing country

CONTEXT

Advanced cases of retinoblastoma are treated with chemoreduction followed by enucleation. Further adjuvant therapy is recommended in patients with known pathologic risk factors (PRFs).

OBJECTIVES

To determine the PRFs in enucleated specimens after chemoreduction and their association for adverse events of recurrence, metastasis, or death.

DESIGN

This was a retrospective study of 77 enucleation specimens from patients treated between January 2000 and September 2008 with prior chemoreduction that were accessioned in the pathology department of a tertiary referral cancer center with an average follow-up of 24 months. Various PRFs were noted and their association with the development of an adverse event was recorded.

RESULTS

Of 77 patients, (male to female ratio, 51∶26), the incidence of overall PRF was 51.9%, and retrolaminar optic nerve invasion (32.5%), optic nerve cut margin (12.9%), massive choroidal invasion (26%), scleral invasion (23.4%), vitreous seedings (44.2%), and anterior segment invasion (20.8%). Undifferentiated tumor (>60%) was seen in 60.3% of cases (41 of 68 patients with differentiation available). Adverse event occurred in 18 of 72 patients with available follow-up (25%). Retrolaminar optic nerve invasion, optic nerve cut margin involvement, and scleral invasion were independent prognostic factors predicting the occurrence of an adverse event. Undifferentiated tumor (>60%) was a significant risk factor in univariate analysis, which is the unique feature in this study.

CONCLUSIONS

Classic PRF with the addition of a predominant presence from the undifferentiated component were associated with adverse outcomes in retinoblastoma treated with anterior chemotherapy. The latter may represent chemoresistant clones and more intensive adjuvant chemotherapy may be warranted in these patients.