Flow Cytometric Assessment of CD26-Positive Leukemic Stem Cells: A Rapid and Valuable Tool in the Diagnosis and Follow-Up of Chronic Myeloid Leukemia

Context Chronic myeloid leukemia (CML) is a clonal myeloproliferative neoplasm. Recent studies have suggested that CD26-positive leukemic stem cells (LSCs) circulating in peripheral blood are specific for CML. Objective This study was undertaken to determine the proportion of CD26-positive LSCs at diagnosis and its change during tyrosine kinase inhibitor therapy. Design This prospective study was conducted on 43 cases of CML at diagnosis. For flow cytometry, peripheral blood cells were stained with CD45, CD34, CD38, CD3, and CD26. A sequential gating strategy with CD45/SSC (side scatter), CD34/SSC, and CD34/CD38 was applied to identify CD45+/34+/38- populations, from which CD26-positive stem cells were identified and compared with controls. Data analysis was done with Kaluza software. Results All patients diagnosed with CML were detected with CD26-positive LSCs. The median percentage of CD26-positive CML LSCs was 0.02 with a range of 0.001 to 1.77. None of the control samples showed CD26 positivity. The percentage and absolute count of CD26-positive CML LSCs were reduced after six months of tyrosine kinase therapy in patients with complete hematological remission. Conclusion Flow cytometric analysis of circulating CD26-positive CML LSCs is a non-invasive, rapid, and useful tool in the diagnosis and follow-up of CML.

Role of CYFRA 21-1 and CEA as prognostic and predictive markers in locally advanced and metastatic gastric carcinoma

PURPOSE

Tumor-associated serum markers have demonstrated predictive and prognostic value in patients being treated for malignancies. However, the clinical importance of tumor markers in gastric cancers (GC) is poorly standardized.

OBJECTIVES

The objective is to assess the clinical utility of cytokeratin-19 fragment (CYFRA 21-1) and carcinoembryonic antigen (CEA) as serum tumor markers in advanced GC.

METHODS

In this prospective study, CYFRA 21-1 and CEA levels were measured at baseline and after three cycles of chemotherapy in patients with advanced GC. The association of tumor marker levels with prognosis and decline of tumor markers with radiological overall response rates (ORR) and survival were analyzed.

RESULTS

In the 105 patients, the proportion of patients with elevated baseline CYFRA 21-1 and CEA levels was 55% (N = 58) and 37% (N = 39) based on predefined cutoffs. Response assessment was done for 61 patients who received a minimum of three cycles of chemotherapy. A 15% and 13% reduction of serum levels from baseline for CYFRA 21-1 and CEA were selected for defining "CYFRA 21-1 response" and "CEA-response," respectively. Both responses were significant predictors of radiological ORR. The median overall survival (OS) was 9.6 months in the entire cohort and 13 months for patients who received at least three cycles of chemotherapy. In multivariate analysis, baseline CEA levels and ECOG status were significant predictors of OS. In a subset analysis of patients receiving palliative chemotherapy, any of the tumor marker responses predicted improved 1-year OS.

CONCLUSION

In advanced GC, CYFRA 21-1 and CEA decline from baseline appeared to be reliable surrogate markers of chemotherapy efficacy and improved survival.

Corrigendum: A combination of metformin and epigallocatechin gallate potentiates glioma chemotherapy in vivo

[This corrects the article DOI: 10.3389/fphar.2023.1096614.].

Clinicopathological features and survival outcomes for gastric adenocarcinoma: Real-world single-center data

INTRODUCTION

Gastric cancer is the fifth most-common cancer and fourth common cause for cancer-related deaths globally. Surgery preceded or followed by chemotherapy or chemoradiotherapy is considered an optimal treatment for locally advanced gastric cancer. This study is a real-world data from a tertiary referral institute in southern India, in its experience with treating gastric adenocarcinoma over a period of four years with a minimum of two-year follow-up.

METHODS

This was a retrospective analysis of data of patients with histologically proven gastric adenocarcinoma enrolled in the Department of Medical Oncology from 2015 to 2018. The demographic details, presentation, staging, treatment received and outcomes of patients with gastric adenocarcinoma were collected and analyzed in this study.

RESULTS

Total 488 patients with gastric adenocarcinoma were included for the study. The stage-wise distribution of patients revealed early and locally advanced (45%) and metastatic (55%). The peritoneum and liver were the common sites of metastasis. The treatment distribution of these patients included perioperative chemotherapy followed by surgery (25 [5%]), surgery followed by adjuvant chemotherapy (65 [13%]), surgery alone (16 [3%]), perioperative chemotherapy alone (23 [4%]), palliative chemotherapy (274 [56%]) and supportive care (85 [17%]). The median overall survival for curative, palliative and supportive treatment was 23 (18-28), nine (7.6-10.4) and four (2.7-5.3) months, respectively. The two-year overall survival in the intention to treat population in the primary surgery (n = 81) and perioperative chemotherapy groups (n = 66) was 67.4% vs. 29.9% (p < 0.0001), respectively.

CONCLUSION

This study highlights the advanced nature of the presentation of gastric cancer patients and the poor rate of treatment completion. The median survival rates in curative patients remain to be dismally poor. The treatment sequence in curable gastric cancer of surgery followed by adjuvant chemotherapy vs. perioperative chemotherapy followed by surgery needs to be explored in our country.

Aggressive Histology and Extensive Metastasis Characteristic of Very Young Gastric Cancer (Less Than 30 Years): A Retrospective Clinical Audit

Narendran KrishnamoorthiObjectives  Gastric cancer (GC) is an aggressive disease and remains one of the most common causes of cancer-related mortality worldwide. Incidence of gastric cancer in young (GCY) varies between 2 and 8%. GCY faces unique challenges such as biological variation, diagnosis at an advanced stage, issues related to fertility preservation, and psychosocial considerations. This study aimed to find the differences in clinical characteristics and treatment outcomes of GCY compared to gastric cancer in older adults (GCO). Material and Methods  This is a retrospective study from a tertiary care center. We screened records from 2015 to 2020, identified 33 records of GCY (less than 30 years), and compared the data with GCO (greater than 30 years) during 2015 and 2018. Results  We identified 33 patients with GCY with a median age of 28 years (21-30) and a female to male ratio of 2:1. In GCY, 60% of patients presented with metastatic disease. Diffuse-type histology was more common in the GCY than in GCO (66.7% vs. 41.7%, p  = 0.001). In patients with metastasis, multiple metastases were common in GCY compared to GCO (45% vs. 15%, p  = 0.003). The median duration of follow-up for all patients was 27 (24-29) months. In GCY, the median OS was not reached for patients treated with curative intent, and it was 13 months for those treated with palliative intent. Conclusion  The incidence of GCY in our study was like the western literature. Female patients with aggressive diffuse histology and multiple extensive metastases were characteristic of GCY. The survival outcomes were identical to GCO.

Negative impact on bone homeostasis in postmenopausal women with non-metastatic breast cancer during cytotoxic chemotherapy

INTRODUCTION

The burden and mechanisms of endocrine therapy-related bone loss are well known, while there are limited data on chemotherapy-induced bone resorption. The study aimed to evaluate the effect of cytotoxic chemotherapy on bone homeostasis among postmenopausal women with non-metastatic breast cancer.

MATERIALS AND METHODS

Early and locally advanced postmenopausal non-metastatic breast cancer patients aged 45 to 65 planned for three cycles of anthracycline and four cycles of taxane chemotherapy administered along with dexamethasone (cumulative dose-256 mg) as an antiemetic from June 2018 to December 2021 were included. Bone mineral density (BMD), bone turnover markers, calciotropic hormones, pro-inflammatory cytokines, oxidative stress, and total antioxidant levels (TAS) were measured.

RESULTS

We recruited 109 patients, with early 34 (31.2%) and locally advanced breast cancer 75 (68.8%) with median age 53 (45-65) years. There was a significant decrease in the % BMD at the lumbar spine, neck of the femur, and total hip post-chemotherapy. There was a significant increase in serum C-terminal telopeptide of type I collagen (CTX) and procollagen type I N-terminal propeptide (PINP) levels post-chemotherapy. PINP/CTX ratio significantly decreased post-chemotherapy. Serum 25-OH vitamin D was significantly reduced with a compensatory increase in plasma iPTH levels. The change in CTX, PINP/CTX ratio, 25-OH vitamin D, iPTH, and oxidative stress index was more pronounced during anthracycline as taxane chemotherapy. There were no significant changes in pro-inflammatory cytokine levels.

CONCLUSION

Chemotherapy and dexamethasone as antiemetic resulted in significant bone loss, as evidenced by bone turnover markers. Further studies are required to understand the mechanism of chemotherapy-induced bone loss and the need for bone-strengthening agents during chemotherapy.

Comparison of Efficacy of Aspirin Plus EOX vs. EOX Alone in Patients with Locally Advanced and Metastatic Gastric Cancer: a Randomized Clinical Trial

PURPOSE

The role of aspirin in cancer prevention has been well defined; the last decade revealed its therapeutic role with improved efficacy when aspirin was added to capecitabine in heavily pre-treated metastatic colorectal cancer. Aspirin affects tumour growth through the PI3K pathway, which regulates apoptosis and autophagy. The objective was to compare the efficacy of aspirin plus epirubicin, oxaliplatin, capecitabine (EOX) chemotherapy versus EOX alone in locally advanced and metastatic gastric cancer.

METHODS

All patients with advanced gastric cancer reporting to the Department of Medical oncology between March 2017 and May 2019 were screened for study eligibility. They were randomly assigned to standard EOX with or without aspirin at a daily dose of 150 mg. Tumour measurements were assessed at baseline and after 3-4 cycles by an independent blinded radiologist according to RECIST criteria 1.1. Toxicity profiles were recorded as per CTCAE v 4.03. Per-protocol group was identified as 70 patients. The primary endpoint was overall response rates in the per-protocol group (defined as patients who received a minimum of 3 cycles and had an evaluable response after randomization). The secondary endpoints included toxicity analysis, progression-free survival, and overall survival.

RESULTS

Ninety-five patients who fulfilled the study inclusion and exclusion criteria were randomized to group 1 EOX (50) or group 2 EOX plus aspirin (45). Seventy patients were included for the per-protocol analysis. The overall response rate in group 1 was 27% compared to group 2, which was 42%, P = 0.176. The median duration of follow was 29 (18.56-39.45) months. The median overall survival (n = 95) of group 1 versus group 2 was 11 (8.58-13.42) months and 10 (6.86-13.14) months, respectively, P = 0.90. There was no statistical significance in the overall survival per-protocol analysis (n = 70) between group one 12 (8.75-15.25) months versus group two 12 (6.21-17.79) months, P = 0.50.

CONCLUSIONS

There was no improvement in the response rates, progression-free survival, and overall survival on adding aspirin to EOX chemotherapy in locally advanced and metastatic gastric cancer in an unselected population. A further role of PI3K mutation as a biomarker needs to be evaluated in this setting.

Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients With Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer

PURPOSE

Anorexia occurs in 30%-80% of patients with advanced malignancies, which may be worsened with chemotherapy. This trial assessed the efficacy of olanzapine in stimulating appetite and improving weight gain in patients receiving chemotherapy.

METHODS

Adults (≥18 years) with untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), and lung cancers were randomly assigned (double-blind) to receive olanzapine (2.5 mg once a day for 12 weeks) or placebo along with chemotherapy. Both groups received standard nutritional assessment and dietary advice. The primary outcomes were the proportion of patients with weight gain > 5% and the improvement in appetite (assessed by the visual analog scale [VAS] and the Functional Assessment of Chronic Illness Therapy system of Quality-of-Life questionnaires Anorexia Cachexia subscale [FAACT ACS]). Secondary end points were change in nutritional status, quality of life (QOL), and chemotherapy toxicity.

RESULTS

We enrolled 124 patients (olanzapine, 63 and placebo, 61) with a median age of 55 years (18-78 years), of whom 112 (olanzapine, 58 and placebo, 54) were analyzable. The majority (n = 99, 80%) had metastatic cancer (gastric [n = 68, 55%] > lung [n = 43, 35%] > HPB [n = 13, 10%]). The olanzapine arm had a greater proportion of patients with a weight gain of > 5% (35 of 58 [60%] v 5 of 54 [9%], P < .001) and improvement in appetite by VAS (25 of 58 [43%] v 7 of 54 [13%], P < .001) and by FAACT ACS (scores ≥37:13 of 58 [22%] v 2 of 54 [4%], P = .004). Patients on olanzapine had better QOL, nutritional status, and lesser chemotoxicity. Side effects attributable to olanzapine were minimal.

CONCLUSION

Low-dose, daily olanzapine is a simple, inexpensive, well-tolerated intervention that significantly improves appetite and weight gain in newly diagnosed patients on chemotherapy.

The Incidence and Severity of Patient-Reported Side Effects of Chemotherapy in Routine Clinical Care: A Prospective Observational Study

INTRODUCTION

Understanding patients' self-reported chemotherapy side effects is significant because it affects patients' quality of life (QOL) and compliance with treatment. Our current knowledge of chemotherapy side effects comes from available literature, whose external validity is questionable. Moreover, there are very few studies available in the literature that focus on various cancers and their associated side effects.

METHODS

A single-center, prospective observational study was conducted at a tertiary care center from July 2019 to July 2021. After deriving the sample size, we interviewed 76 consecutive study patients with gastric, periampullary, colorectal, and breast cancer for six months after chemotherapy initiation with a structured patient-reported outcome tool adapted in English and Tamil to record the side effects like diarrhea, vomiting, chest pain, constipation, dyspnea, fatigue, mucositis, and rash. The grading of symptoms was done according to the Common Terminology Criteria for Adverse Events version 5.0. The frequency and prevalence of side effects were calculated as the number of patients who reported the side effect of any grade at least once during the follow-up period. The incidence rate of side effects was calculated in terms of person-time. The association between each side effect and cancer type was calculated using the chi-square test and Fisher's exact test as appropriate.

RESULTS

Of the 77 patients in the study, 51.9% were male, 63.6% were between 40 and 60 years of age, 45.5% had stage-3 disease, and 44.2% received neoadjuvant treatment. During the six-month follow-up period, 97.4% of patients experienced at least one side effect. Fatigue was the most common side effect (87%), followed by loss of appetite (71.4%) and diarrhea (49.4%). Approximately 66.7% of patients experienced six or more side effects. There was a statistically significant difference in the frequency of side effects between cancer types. However, age, socioeconomic status, BMI, comorbidity, chemo-intent, and stage of disease did not affect the frequency of side effects.

CONCLUSIONS

This study highlights the need to integrate patient-reported side effects into routine clinical practice. Identifying these side effects, even if they are mild in intensity, and managing them in a timely manner may improve the patient's emotional state, QOL, and compliance with chemotherapy.

Efficacy and safety of pomalidomide, bortezomib, and dexamethasone combination chemotherapy for newly diagnosed multiple myeloma: POMACE Phase II Study

Bortezomib, lenalidomide, and dexamethasone induction chemotherapy (VRd), followed by autologous stem cell transplantation (ASCT), are the standard of care for patients with newly diagnosed multiple myeloma (NDMM). Pomalidomide is currently approved for relapsed-refractory multiple myeloma. This single-arm, open-label, phase 2 study was the prospective evaluation of the efficacy and safety of bortezomib, pomalidomide, and dexamethasone (VPd) induction for NDMM. We used Fleming's two-stage design for sample size calculation. We included transplant-eligible and ineligible patients aged 18-75 years in the study. The patients received four cycles of VPd induction followed by response assessment. Thirty-four patients were included in the study, of which 31 completed all four cycles of induction. The median age was 52 years (32-72). Thirty (91%) patients had multiple myeloma, and three had multiple plasmacytomas with less than 10% bone marrow involvement. Nine (27%) had ISS-I, 9 (27%) had ISS-II, and 15 (46%) had ISS-III myeloma. Three patients had high-risk cytogenetic abnormalities. After four cycles of VPd induction, ten patients (32%) achieved stringent CR, nine had CR (29%), eight (26%) had VGPR, and 4 (13%) had PR. Fifteen (48%) had a complete metabolic response (CMR) on PET-CT. Two patients developed SAEs. Anemia was the most common hematological toxicity. Peripheral neuropathy and constipation were the most common non-hematological toxicities. Patients with ≥VGPR had significantly better 12-month PFS than those with PR. Patients with ≥VGPR and CMR on PET-CT had significantly better 12-month OS. Our study showed VPd induction is safe and efficacious in NDMM. Further Phase 3 studies are necessary to establish the superiority and survival benefits.

Optimising platelet usage during the induction therapy of acute myeloid leukaemia: Impact of physician education

INTRODUCTION

Platelet products are scarce and expensive resources to be used judiciously. However, inappropriate usage is common. Lack of physician awareness is an important issue. We implemented a physician education program (PEP) along with repeated WhatsApp reminders at our centre. We audited the platelet usage practise before and after the intervention.

METHODS

Charts of patients with acute myeloid leukaemia (AML) treated between January 2020 and August 2020 was reviewed, and the mean platelet usage per patient per day was calculated. Physician education was implemented between September 2020 and December 2020 (2 PowerPoint lectures of 20 min each and weekly WhatsApp messages containing the guidelines). Data of patients treated between Jan 2021 and August 2021 was prospectively audited to understand platelet usage and the indications for transfusions. The British Committee for the Standards in Haematology (BCSH) platelet transfusion guidelines were used as the adjudication tool to evaluate compliance. The mean platelet usage per day per kg body weight of a patient before and after the PEP was compared using the t-test.

RESULTS

Group A (before physician education) consisted of 22 patients, and group B (after physician education) consisted of 23 patients. The mean number of platelet transfusions for each patient in a day per kg body weight was 125.7 × 10⁸ in group A whereas, after the PEP, it had reduced to 73.9 × 10⁸ amounting to an absolute reduction of 51 × 10⁸ (58.8%) from the baseline with a statistical significance of P = 0.001. After implementing the PEP, the mean number of random donor platelets used reduced by 10.25 units (34% reduction), and the mean single donor platelets used reduced by 0.83 units (19% reduction). The 190 requests for platelet transfusion received during this period were classified as appropriate (157/190), which constituted 82.63% of the requests, or inappropriate (33/190), which accounted for 17.36%.

CONCLUSIONS

A short-duration education programme supplemented with weekly WhatsApp messages and an active feedback mechanism on the rationale of platelet transfusion by the treating physician and transfusion specialist could significantly reduce platelet consumption during the therapy of acute myeloid leukaemia patients. This is a measure that can be considered by all high-volume haematology centres, which can improve patient safety and reduce costs.

A combination of metformin and epigallocatechin gallate potentiates glioma chemotherapy in vivo

Glioma is the most devastating high-grade tumor of the central nervous system, with dismal prognosis. Existing treatment modality does not provide substantial benefit to patients and demands novel strategies. One of the first-line treatments for glioma, temozolomide, provides marginal benefit to glioma patients. Repurposing of existing non-cancer drugs to treat oncology patients is gaining momentum in recent years. In this study, we investigated the therapeutic benefits of combining three repurposed drugs, namely, metformin (anti-diabetic) and epigallocatechin gallate (green tea-derived antioxidant) together with temozolomide in a glioma-induced xenograft rat model. Our triple-drug combination therapy significantly inhibited tumor growth in vivo and increased the survival rate (50%) of rats when compared with individual or dual treatments. Molecular and cellular analyses revealed that our triple-drug cocktail treatment inhibited glioma tumor growth in rat model through ROS-mediated inactivation of PI3K/AKT/mTOR pathway, arrest of the cell cycle at G1 phase and induction of molecular mechanisms of caspases-dependent apoptosis.In addition, the docking analysis and quantum mechanics studies performed here hypothesize that the effect of triple-drug combination could have been attributed by their difference in molecular interactions, that maybe due to varying electrostatic potential. Thus, repurposing metformin and epigallocatechin gallate and concurrent administration with temozolomide would serve as a prospective therapy in glioma patients.

Cytotoxic chemotherapy is associated with decreased bone mineral density in postmenopausal women with early and locally advanced breast cancer

PURPOSE

The burden and mechanisms of endocrine therapy-related bone loss have been studied in detail. However, there is limited data regarding cytotoxic chemotherapy's impact on bone health. There are no definitive guidelines for bone mineral density (BMD) monitoring and treatment with bone-modifying agents during cytotoxic chemotherapy. The study's primary objective was to evaluate the changes in BMD and fracture risk assessment tool (FRAX) scores among breast cancer women on cytotoxic chemotherapy.

METHODS

One hundred and nine newly diagnosed early and locally advanced postmenopausal breast cancer patients planned for anthracycline and taxane-based chemotherapy were recruited prospectively during the study period from July 2018 to December 2021. BMD of the lumbar spine, the femoral neck, and the total hip were assessed by dual-energy X-ray absorptiometry scan. BMD and FRAX scores were evaluated at baseline, end of chemotherapy, and 6 months of follow-up.

RESULTS

The median age of the study population was 53 (45-65) years. Early and locally advanced breast cancers were seen in 34 (31.2%) and 75 (68.8%) patients, respectively. The duration of follow-up between two BMD measurements was 6 months. The percentage of decrease in BMD at the lumbar spine, femoral neck, and total hip were - 2.36 ± 2.90, - 2.63 ± 3.79, and - 2.08 ± 2.80, respectively (P-value = 0.0001). The median risk of major osteoporotic fracture (MOF) at 10 years (FRAX score) increased from 1.7 (1.4) to 2.7% (2.4) (P-value = 0.0001).

CONCLUSION

This prospective study in postmenopausal breast cancer women shows a significant association of cytotoxic chemotherapy with the worsening of bone health in terms of BMD and FRAX score.

Immunohistochemistry-based molecular classification of gastric cancer in India: How are we different?

462

Background: TCGA and ACRG have classified gastric cancer (GC) into molecular subgroups using genomics. We attempted to classify GC from our region using IHC (Immunohistochemistry) to understand its prognostic significance and compare with similar data from other parts of the world. Methods: This was a retrospective cohort of GC patients from years 2017-18. EBV (LMP), MSI (MLH1, MSH2, PMS2, MSH6),p53, E-cadherin and PIK3CA were assessed by IHC. Clinicopathological characteristics and survival were evaluated for association with molecular subtypes as defined by TCGA and ACRG classification system. Results: A total of 191patients were included with EBV positivity 35 (18.3 %), MSI 33(17.3 %), p-53 aberration 25(13.1%), E-cadherin negative (29.3%). On univariate analysis, p53 aberration was associated with higher age (>60 yrs), E- cadherin negative with diffuse histology & antro-pyloric region as predominant site. MSI with intestinal histology & antro-pyloric region as predominant site with MSI. The TCGA classification revealed EBV 35 (18%), MSI 28 (15 % ), GS 48 (25 %) and CIN 80 (42% ) subtypes respectively. CIN subtype was seen predominantly above 40 yrs of age (P=0.04), GS subtype was frequently associated with diffuse histology P<0.0001. The ACRG classification revealed MSI 33(17%), MSS/EMT 51 (26.7%), MSS/ p53 normal 91 (47.6%) and MSS/p53 aberrant 16 (8.4) subtypes. MSS/E-cad- subtype was associated with diffuse histology. PIK3CA positivity was higher in CIN (TCGA )& MSI (dmr) (ACRG) respectively. The median OS in MSI was 35 and 32 months higher compared to other subtypes (P<0.0001) in TCGA and ACRG classification respectively. Conclusions: The TCGA and ACRG classification identified molecular subtypes based on IHC from our region and significantly correlated with clinical factors and survival. PIK3CA as an additional marker may be further explored to be included in the classification system. Abbreviation: EBV - Epstein–Barr-virus, MSI – Microsatellite-Instability, GS- Genomic-instability, CIN- Chromosomal-instability, MSS- Microsatellite-stable, EMT-Epithelial-mesenchymal-transition.[Table: see text]

Nomogram to predict peritoneal dissemination in gastric cancer

465

Background: Peritoneal metastasis is a poor prognostic factor in patients with gastric cancer and cannot be predicted, that can tailor oncological treatment. We retrospectively analyzed the clinicopathological data among 110 gastric cancer patients. Methods: Univariate logistic regression was performed with peritoneal disease as the outcome to assess potential risk factors associated with it. We found that age, gastric outlet obstruction, VEGF, Ki67, p53 and NLR ratio were significant factors associated with peritoneal disease. Using multiple logistic regression, the adjusted odds ratio and 95% confidence interval were estimated. The predictive accuracy of this regression model was estimated using ROC curve analysis and Area under the curve, sensitivity and specificity were estimated. A nomogram was plotted based on the regression coefficient for the prediction of peritoneal disease. Results: It was estimated that age less than 40 years had 0.19 (0.05, 0.79), GOO positive had 2.04 (0.69, 6.03), VEGF positive had 4.69 (1.79, 12.33), elevated Ki67 had 3.94 (1.55, 9.97), positive p53 had 0.43 (0.17, 1.11) and NLR ratio had 1.15 (0.88, 1.51) odds of having peritoneal disease from multiple logistic regression. The regression model had significant goodness of fit for the data (Hosmer-Lemeshow test P value < 0.001). On estimating the AUC from the ROC curve for the model, we found that it had a good discriminatory ability with AUC = 0.81. Sensitivity was estimated to be 71.15%, whereas specificity was estimated to be 72.41% for the model. Subsequently, a nomogram was plotted based on the regression estimated from this model. Conclusions: The nomogram could risk-stratify those at risk of developing peritoneal disease and modify therapeutic strategies like selecting patients for prophylactic intraperitoneal chemotherapy or other novel therapeutic strategies. However, the nomogram needs to be validated prospectively.

Pattern of expression of CDX2 in colorectal cancer and its role in prognosis

Background

CDX2, a nuclear protein, is essential for the proliferation and development of intestinal epithelial cells and is frequently down-regulated during tumorigenesis. We have evaluated the pattern of CDX2 expression in all stages of colorectal cancer (CRC) and its association with prognosis.

Methods

We performed CDX2 staining by immunohistochemistry (IHC) on the available biopsy blocks of patients of CRC registered in our institute from January 2014 to January 2018. CDX2 scoring was done using the semi-quantitative method.

Results

A total of 286 patients were registered during the study period, of which only 110 biopsy blocks were available for staining. Of 110 patients, 77 (70%) had colon cancer and 33 (30%) had rectal cancer. The median age was 54.2 years, with 62 (56.4%) being male and 48 (43.6%) female with a male to female ratio of 1.3:1. In the study cohort, 33 (30%) patients had stage II disease, 30 (27.3%) had stage III, and 47 (42.7%) had stage IV. Seventy-three (66.4%) were positive for CDX2 and 37 (33.4%) were negative. Loss of CDX2 expression was significantly associated with advanced stage, rectal site, poor grade of differentiation, and presence of lymphovascular invasion. With a median follow-up of 16 months, progression-free survival (PFS) at 2 years was 30% for CDX2-negative patients compared to 67% for CDX2-positive patients (P = 0.009), whereas the overall survival (OS) at 2 years was 46% for CDX2-negative versus 77% for CDX2-positive patients (P = 0.01).

Conclusion

Loss of CDX2 expression is associated with advanced stage, higher tumor grade, presence of LVSI, worse PFS, and OS and thereby functions as a poor prognostic factor in CRC.

Outcomes of Allogeneic Stem Cell Transplant in Chronic Myeloid Leukemia - Blast Phase: A Single-center Experience from South India

The blast phase (BP) is challenging to treat and leads to inferior survival in chronic myeloid leukemia (CML). Allogeneic hematopoietic stem cell transplant (AlloSCT) is the only curative option for CML-BP. We are sharing our experience of AlloSCT in seven patients with CML-BP who underwent transplants during the period from January 2017 to December 2019. Three patients each had myeloid-BP, lymphoid-BP, and one patient had mixed phenotypic BP. Donors were matched siblings in four, mismatched siblings in one, and haploidentical in two. All patients received peripheral blood stem cell grafts. The median CD34+ dose was 7.6 (range: 6.6–8.9) × 106 cells/kg. Neutrophil engraftment was observed at a median of 15 (10–20) days and platelet engraftment at 19 days (10–22). At a median follow-up of 24 months, the 2-year leukemia-free survival (LFS) and overall survival (OS) were 43% and 57%, respectively. Transplant-related, non-relapse mortality was observed in three patients. AlloSCT results in promising survival for carefully selected patients of CML-BP, especially with a matched sibling donor.

Pattern of Expression of CDX2 in Colorectal Cancer and its Role in Prognosis: An Ambispective Observational Study

Introduction Caudal-type homeobox 2 (CDX2), a nuclear protein, is essential for the proliferation and development of intestinal epithelial cells and is frequently downregulated during tumorigenesis. CDX2 inhibits cell growth as well as stimulates differentiation by activating intestinal specific genes, thus lack of CDX2 favors tumor growth and aggressiveness.

Objectives We aimed to evaluate the pattern of CDX2 expression in all stages of colorectal cancer (CRC) and study its association with baseline characteristics and prognosis.

Materials and Methods Study was conducted as an ambispective observational study, enrolling cases of CRC retrospectively from January 2014 to July 2016 (30 months), and prospectively during next 18-month period till January 2018. We performed CDX2 staining by immunohistochemistry on the available biopsy blocks of CRC patients during the study period. Total 286 patients were registered during the study period, of which only 110 biopsy blocks were available for staining. CDX2 scoring was done by a semiquantitative method on whole tissue section for the intensity and percentage of the cells showing positivity. Correlation of CDX2 expression was done with baseline clinical and histopathologic characteristics, and survival.

Results Of 110 patients, 77 (70%) constituted colon cancer and 33 (30%) were rectal cancer. The median age was 54.2 years, 62 (56.4%) being male and 48 (43.6%) female with male-to-female ratio 1.3:1. In the study cohort, 33 (30%) patients had stage II disease, 30 (27.3%) stage III, and 47 (42.7%) were stage IV. Seventy-three (66.4%) were positive for CDX2 and 37 (33.4%) were negative. Loss of CDX2 expression was significantly associated with advanced stage, rectal site, poor grade of differentiation, and presence of lymphovascular invasion (LVSI). With median follow-up of 16 months, progression-free survival (PFS) at 2 years was 30% for CDX2 negative patients compared with 67% for CDX2 positive (p = 0.009), while overall survival (OS) at 2 years was 46% for CDX2 negative versus 77% for positive patients (p = 0.01).

Conclusion Loss of CDX2 expression is associated with advanced stage, higher tumor grade, presence of LVSI, and worse PFS and OS and thereby functions as a poor prognostic factor in CRC.

Double Infection in a Patient with Chronic GVHD Post Allogeneic Transplant: “Hickam's Dictum” Trumps “Occam's Razor”!—A Case Report with Review of Literature

Double pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.

Phase II study of sodium valproate in combination with oral etoposide in platinum-resistant ovarian cancer

Patients with platinum-resistant ovarian cancer (PROC) have limited therapeutic options and poor survival. There is a need for the development of newer therapies. Sodium valproic acid (VPA) is a short-chain fatty acid histone deacetylase (HDAC) inhibitor with antitumor activity in preclinical models of PROC. Synergism with conventional cytotoxic agents like etoposide has been demonstrated. In this prospective, single-arm, open-label, phase 2 study, we included patients ≥ 18 years with histologically or cytologically confirmed PROC and Eastern Cooperative Oncology Group performance status (ECOG-PS) 0–3. Patients received oral VPA 60 mg/kg/day in three divided doses for 3 days (D1–D3), followed by oral etoposide 50 mg once daily for two consecutive weeks (D4–D17). Serum samples were collected to assess peak VPA drug levels. The primary endpoint was the overall response rate (ORR). The secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity. We sought to show an improvement in response rate from 25% (historically with oral etoposide) to 40% with the addition of VPA. 27 patients were enrolled in the study, and 18 [median age: 52 (45–59) years; serous histology:17 (94%); ECOG-PS 2 or 3: 14 (78%)] were evaluable for the response after 4 months. Nine patients were lost from follow-up before achieving the primary endpoint (mainly due to Covid-related lockdown issues). The median number of prior lines of treatment was 2 (1–3). ORR was 0% according to GCIG criteria. The disease was stable in two patients [clinical benefit rate (CBR) of 11%]. The median OS and PFS were 7 months and 2 months, respectively. Grade ≥ 3 adverse events were reported in 6 (33%) patients. The addition of valproic acid to oral etoposide in patients with PROC and poor general condition was not helpful and failed to improve responses compared to those historically achieved with single-agent etoposide. However, further phase 2 randomized controlled trials with larger sample size can be done to confirm the findings.

Systemic Immune-Inflammation Index Predicts Outcomes in Platinum-Resistant Relapsed Ovarian Cancer

We explored the prognostic impact of simple indices that reflect the immunological milieu (neutrophils to lymphocyte ratio [NLR] and systemic immune-inflammation [SII]) in 49 platinum-resistant relapsed ovarian cancer patients. The median progression-free survival (PFS) and overall survival (OS) were 4 and 8 months, respectively. Patients with a lower NLR (≤2.89) had a better PFS (5 vs. 2 months [p = 0.02]) and OS (9 vs. 5 months [p = 0.20]). Factors associated with a worse PFS were NLR > 2.8 (hazard ratio [HR] =2.32, p = 0.02) and SII > 639 (HR =3.70, p = 0.002). SII > 639 independently predicted PFS (HR =4.13, p = 0.03). Future studies should study the validity of inflammatory markers and could consider incorporating it as a biomarker in clinical trials.

Bilateral CMV Retinitis in a Patient with Relapsed Non-Hodgkin Lymphoma on Oral Metronomic Chemotherapy: Case Report and Review of Literature

Cytomegalovirus (CMV) retinitis is one of the common complications in profoundly immunosuppressed patients such as those with acquired immune deficiency syndrome. It has been rarely reported in patients with lymphoma on aggressive chemotherapy. We encountered a patient with bilateral CMV retinitis who developed this vision-threatening complication while on low-dose palliative metronomic chemotherapy with oral drugs (cyclophosphamide, procarbazine, etoposide, and prednisolone). Though the infection resolved with treatment, there was residual vision loss. This case is presented to sensitize clinicians to the possibility of unusual infections in patients on long-term oral chemotherapies.

Role of Neoadjuvant Chemotherapy in Locally Advanced Carcinoma Stomach: An Analysis of the Short-Term Outcomes

Introduction: Neoadjuvant chemotherapy (NACT) in carcinoma stomach was introduced in an effort to eliminate micro-metastasis and to improve resectablity before surgery which improves R0 resection rates. We aimed to study the short term outcomes of neoadjuvant chemotherapy on the Tumor Node Metastasis (TNM) stage and the operative outcomes including R0 resection rate in locally advanced gastric cancer.

Methods: We prospectively included patients with locally advanced adenocarcinoma stomach staged by contrast-enhanced computed tomography (CECT) in our study. Patients in Group I were started on neoadjuvant chemotherapy (epirubicin, oxaliplatin, and capecitabine). Surgery was done following response assessment CECT. Patients in Group II underwent upfront surgery. We assessed R0 resection rate, number of harvested and metastatic lymph nodes, lymph node ratio, duration of surgery, blood loss, hospital stay and complications between two groups. Response to NACT was assessed in Group I.

Results: Out of 47 patients who received NACT, two patients had complete response (4.2%), 13 had partial response (27.7%), 10 had stable disease (21.3%) and 22 patients had progressive disease (46.8%). We found no significant difference in the rate of R0 resection between the two groups (88.2% in NACT group vs 85.1% in surgery group, P=0.55).

Conclusions: The rate of R0 resection does not significantly improve with neoadjuvant chemotherapy. In view of high progression rates, patient selection is required when NACT is planned in carcinoma stomach which are surgically resectable at presentation. We await survival analysis to further validate the role of NACT.

Use of "Repurposed" Drugs in the Treatment of Epithelial Ovarian Cancer: A Systematic Review

Epithelial ovarian cancer has poor outcomes with standard therapy and limited options for treatment of recurrent disease. This systematic review summarizes the data on the clinical use of repurposed drugs. We searched for clinical studies using "repurposed" agents for the treatment of ovarian cancer in the following databases: PubMed, clinicaltrials.gov, Clinical Trial Registry of India, European Clinical Trials Registry, and Chinese Clinical Trial Registry. We excluded reviews, preclinical studies, and non-English language studies. We assessed the quality of included studies. The following agents/class of agents were included: statins, hydroxychloroquine, metformin, itraconazole, nonsteroidal anti-inflammatory drugs, vitamin D, proton pump inhibitors, beta-blockers, and sodium valproate. Only one randomized controlled trial investigated metformin, which found no benefit of metformin. However, this had a high risk of bias (no details of randomization). Among the observational studies, 70% were of high quality (Newcastle-Ottawa scale ≥7). Clinical benefit was seen for itraconazole, beta-blockers, metformin, statins, and proton pump inhibitors. Though multiple studies aim to repurpose agents in epithelial ovarian cancer, the most published literature is observational, and none are practice-changing. Given the solid preclinical data regarding the anticancer efficacy of these agents, well-designed clinical trials are urgently required.

Outcome of CBV (Carmustine, Cyclophosphamide, Etoposide) Conditioning Regimen for Autologous Stem Cell Transplant in Lymphoma: A Retrospective Study from a Tertiary Cancer Center in South India

Background In autologous stem cell transplant (ASCT) for lymphomas, no standard conditioning regimen has been defined so far. Thus, the choice is guided by the center's familiarity and experience with a particular regimen.

Objective To determine the response, toxicity, and survival outcomes in lymphoma patients who underwent ASCT with CBV (cyclophosphamide, carmustine, and etoposide) conditioning regimen.

Materials and Methods Between January 2013 and May 2019, 45 consecutive lymphoma patients who had ASCT with CBV conditioning regimen were included in this retrospective study. CBV consisted of cyclophosphamide (1.5 g/m2/day × 4 days), carmustine (300 mg/m2 × 1 day), and etoposide (125 mg/m2 twice daily × 3 days). Baseline characteristics, pre transplant response, apheresis, post-transplant toxicities, post-transplant response, and survival outcomes were collected. Endpoints were toxicity, response, event-free survival (EFS), and overall survival (OS).

Results The median age was 30 (range: 6–64) years. Diagnosis was Hodgkin lymphoma (HL) in 26 (58%) and non-Hodgkin lymphoma (NHL) in 19 (42%). Forty-three patients (95%) had chemosensitive disease; 22(49%) in CR, and 21 (46%) in PR. The median CD34 was 2.95 × 106/kg (range: 0.9–9.56). The median time to neutrophil engraftment was 11 days (9–23) and 13 (8–36) days for platelets. All patients had febrile neutropenia, clinically and/or microbiologically documented infection was seen in 75% of patients. The most common grade 3/4 toxicities were mucositis (n = 4, 9%), diarrhea (n = 4, 9%), and nausea/vomiting (n = 2, 4%). The average days of hospitalization was 18 (range: 10–37). Day 100 mortality was 6.6% (n = 3). The median follow-up was 44.8 months. The median EFS for the entire cohort was 23.8 months; for HL, the median EFS was not reached, and for NHL, it was 7.97 months (95% confidence interval [CI]: 1.57–14.37). The median OS for the entire cohort and for HL was not reached; for NHL, it was 24.3 months (95% CI: 0.56–48.11).

Conclusion CBV conditioning regimen was well tolerated with low grade 3/4 toxicities and efficacy comparable to literature data.

Outcomes of HIDAC 18 g Versus IDAC 9 g in Consolidation Therapy of Acute Myeloid Leukemia: A Retrospective Study

BACKGROUND

Cytarabine based therapy has been the standard consolidation regimen for AML (acute myeloid leukemia) for decades. However, the optimal dose, regimen and schedule is not known. HIDAC (high dose cytarabine at 18 g/m²) has been the conventional standard, however, recent studies have shown that intermediate doses of cytarabine (IDAC) have equal efficacy and lesser toxicities.

METHODS

We retrospectively analysed 75 AML patients who entered consolidation out of 167 patients who underwent induction therapy between 2014 and 2018. HIDAC (at 18 g/m²) was given to 39 patients and 36 patients received IDAC at 9 g/m².

RESULTS

Median age was 28 years (range 2-60). Male: female ratio was 1.02. More courses were administered in out-patient setting in IDAC group 61% (n = 58/95 courses) than in HIDAC 29% (n = 29/101 courses); p < 0.001. Incidence of clinically documented infection (CDI) was higher in HIDAC group (23.7%) compared to IDAC (8.4%), p = 0.004, and diarrhea showed a higher trend in the HIDAC group (9.9% vs. 3.1%; p = 0.052). Other toxicities were similar in both groups. There were 4 consolidation deaths in HIDAC whereas 3 deaths in IDAC group (p = 0.775). Median OS was 19.7 vs. 16.2 months and 3 years OS was 49.1% vs. 34.7% in HIDAC and IDAC groups respectively (p = 0.570). Median LFS was 12.6 versus 11.8 months; 3 years LFS was 46.4% versus 31% in HIDAC and IDAC groups respectively (p = 0.278).

CONCLUSION

For AML consolidation IDAC had lesser toxicity when compared with HIDAC though comparable efficacy needs to be confirmed with longer follow up and with prospective studies.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12288-021-01430-z.

Plerixafor use in autologous hematopoietic stem cell mobilization: Experience from a single center in Southern India

BACKGROUND:

Plerixafor is used for patients at risk of Stem cell mobilization failure based on clinical factors or low peripheral blood CD34 count. It is also added upfront to any mobilization irrespective of risk factor, but the cost-effectiveness of the approach is an issue. Data on plerixafor in different settings of autologous hematopoietic stem cell (HSC) collection from India are scant. We are hereby reporting the experience of failure/success of mobilization rate and few important significant variables (CD34+ dosage, failed collection) between plerixafor and granulocyte colony-stimulating factor alone groups among autologous hematopoietic stem cell transplantation (aHSCT) at our institute.

METHODS:

This was a record-based single-center study on patients who underwent aHSCT from January 2013 to June 2019 at a tertiary care hospital. Descriptive statistics were used for baseline characteristics, transplant-related factors, and peritransplant outcomes. All statistical analyses were performed at the 5% significance level.

RESULTS:

During the study duration, a total of 96 patients had undergone autologous hematopoietic stem cell collection (aHSCC), all by peripheral blood stem cell harvest, requiring 131 apheretic collections. Of the total 131 collections in 96 patients, plerixafor was used in 63 apheresis collections (48% of total pheresis) in 40 patients. Among the 40 patients who were administered plerixafor to augment the collection, 34 patients had upfront use of plerixafor. We did not observe any significant adverse event related to plerixafor use.

CONCLUSION:

A rational utilization of plerixafor can facilitate the process and logistics of aHSCC outcome.

Challenges in the Management of Lung Cancer: Real-World Experience from a Tertiary Center in South India

Lung cancer is one of the most common cancers and an important cause of cancer-related mortality. Recent advances in targeted therapy and immunotherapy have improved outcomes, but these have limited penetration in resource-constrained situations. We report the real-world experience in treating patients with lung cancer in India. A retrospective analysis of baseline characters, treatment and outcomes of patients with lung cancer seen between January 2015 to December 2018 ( n = 302) at our center was carried out. Survival data were censored on July 31, 2019. A total of 302 patients (median age: 57 years [range, 23–84 years]; males [ n = 203; 67.2%]) were registered. Adenocarcinoma was the most common histology ( n = 225, 75%). The testing rate of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation analysis in stage IV adenocarcinoma ( n = 191) was 67% and 63%, respectively. Systemic therapy (chemotherapy/gefitinib) was started after a median of 62 days (range, 1–748) from presentation and 38 days (range, 1–219 days) from diagnosis. The median progression-free survival (PFS) and overall survival (OS) were 4.3 months (95% CI, 3.2–5.4) and 9.0 months (95% CI, 7.6–10.5), respectively in the 141 patient without targetable mutations who started palliative chemotherapy. Of the 58 patients who tested positive for EGFR mutation, 41 (71%) started an EGFR tyrosine kinase inhibitor (TKI), and the median PFS and OS in these patients were 8.5 months (95% CI, 5.6–11.4) and 18.4 months (95% CI, 12.2–24.6), respectively. Only 1 out of 10 patients with stage IV ALK -positive adenocarcinoma was started on ALK inhibitor. On multivariate analysis of OS for patients who started on palliative chemotherapy, response to first-line treatment, long distance from the center, use of second line therapy, and a delay of > 40 days from diagnosis to treatment predicted improved survival. Despite providing free diagnostic and treatment services, there was considerable delay in therapy initiation, and a significant proportion of treatment noninitiation and abandonment. Measures should be taken to understand and address the causes of these issues to realize the benefits of newer therapies The apparent paradox of improved survival in those with long delay in initiation of treatment could be explained based on a less aggressive disease biology.

Post-chemotherapy Changes in Bone Marrow in Acute Leukemia With Emphasis on Detection of Residual Disease by Immunohistochemistry

Introduction

In acute leukemia, the leading cause of treatment failure is disease relapse leading to a low level of complete remission and short overall survival. Post-chemotherapy marrow examination gives vital clues regarding treatment response and marrow regeneration.

Aim

We aimed to study the histomorphological changes in post-chemotherapy bone marrow in acute leukemias, monitor residual disease by immunohistochemistry (IHC) on trephine biopsy, and correlate survival status.

Method

This study was a prospective clinical study. A total of 155 post-induction cases (acute myeloid leukemia [AML] - 68 and acute lymphoblastic leukemia [ALL] - 87), from January 2014 to December 2015, were included with a follow-up of 4-28 months. A detailed histomorphology was studied in all cases. IHC was applied in 88 cases of post-induction marrow, which showed morphologic suspicion of an increase in blasts.

Observations

Post-induction marrow was hypercellular in 55.9% of AML and normocellular in 56.3% of ALL. Regenerative hematopoiesis was noted in 37.4% of AML and 88.5% of cases of ALL. Marrow serous atrophy and stromal edema were associated with delayed recovery of counts and their recovery duration ranged from one to five months. Twenty-seven bone marrow aspirates were unsatisfactory, and their trephine biopsies were showed remission in 20 cases and stromal changes in nine cases. In addition, trephine biopsy picked up residual leukemic blasts in four cases in which aspirate showed remission status. Post-induction marrow IHC with scattered positivity for blasts showed sustained remission in 96% cases, and in those with clustered positivity, 28.6% showed residual disease, and 7.2% showed relapse at the end of the study period. The median survival duration was 13, 3, and 12 months for cases with sustained remission, residual disease, and relapse, respectively. There was a statistically significant difference in median survival of patients in the three groups (sustained remission, residual disease, and relapse) (p=0.000).

Conclusion

We conclude that histomorphology augmented by IHC on trephine biopsy gives valuable information regarding post-chemotherapy changes and residual disease status. Bone marrow trephine biopsy is an important tool to assess the remission status of patients with acute leukemia.

Clostridioides difficile Diarrhea: An Emerging Problem in a South Indian Tertiary Care Hospital

Context Clostridioides difficile infection (CDI) is one of the most common infectious causes of hospital-acquired diarrhea. The actual burden of the disease is underestimated in India due to inadequate diagnostic methods and limited studies conducted.

Aims The aim of this study was to determine the burden and risk factors of CDI among patients with hospital-acquired diarrhea.

Methods and Materials Stool specimen of patients (age > 1 year) with hospital-acquired diarrhea were screened for glutamate dehydrogenase antigen and toxin using an enzyme immunoassay. If both antigen and toxin were present, it was reported as positive for toxigenic CDI. Samples positive for antigen and negative for toxin were further tested with Cepheid GeneXpert assay for detecting the toxin producing gene.

Results Of 75 patients (mean age 36.07 ± 20.79, 64% males), 14 (18.67%) patients were positive for toxigenic Clostridioides difficile (C. difficile) and 3 (4%) patients were nontoxigenic C. difficile. Addition of GeneXpert to the testing algorithm increased the yield of toxin detection in 5/14 patients who were negative by toxin assay. On analysis of risk factors, prolonged hospital stay was found to have significant association (p-value = 0.022). Patients with factors like intensive care unit stay, presence of diabetes mellitus as a comorbidity, and exposure to antibiotics like carbapenems and glycopeptides have been found to have a higher prevalence of CDI.

Conclusions The prevalence of CDI in our population was 18.67% and the major risk factor associated was prolonged hospital stay. The addition of GeneXpert for the detection of toxin gene increased the yield from 12 to 18.68%.

Surveillance Stool Culture and its Association with Microbiologically Documented Infection During Febrile Neutropenia in Patients with Acute Leukemia (AL) Undergoing Induction Chemotherapy

The study aimed at identifying the profile of gut colonization of patients with acute leukemia who underwent induction chemotherapy and its association with induction events and outcome. Baseline bacterial stool culture with resistance pattern of isolates were recorded. Multi-drug resistance was defined as resistance to at least two antibiotic classes including beta lactam and fluoroquinolones. During induction chemotherapy, blood and clinically indicated cultures were taken during febrile neutropenic episodes. Association studies were done between gut colonization and induction events/outcome. Among 109 patients enrolled, 71 (65.13%) patients undergoing induction chemotherapy were colonized with bacteria, with nearly 50% of colonizers harboring multi-drug resistant bacteria. Organisms isolated from stool pre-induction were mostly gram negative (98%), with Escherichia coli and Klebsiella pneumoniae being the commonest. 65.13% patients developed febrile neutropenia. Overall multi-drug resistant positivity during febrile neutropenia was 70.14%. Concordance of 8.45% was observed between isolates from stool and organisms isolated from cultures during febrile neutropenia. There were significant proportion of gut colonized gram-negative multi-drug resistance bacteria among patients with acute leukemia. There was a low concordance rate between baseline stool isolates and subsequent cultures during the induction. There was no significant association between gut colonization and induction events/outcomes studied.

Assessment of Oral Anticancer Medication Adherence: A Survey from a Tertiary Cancer Center

Background Adherence to oral anticancer medication is important in cancer chemotherapy, with the advent of many oral anticancer regimens to ensure adequate cytologic response. Literature on adherence to oral anticancer therapy in India is very less. Materials and Methods This is a cross sectional analytical study consisting of all fit patients > 18 years of age taking oral anticancer therapy, with or without intravenous (IV) chemotherapy. Adherence was determined using Morisky-Green-Levine (MGL) scale, and factors affecting adherence details about cancer and treatment were obtained. All fit patients were recruited. Information was obtained using Tamil questionnaire and pro forma. Observation Of 152 patients, only 111 patients were found to be adherent to treatment. The mean age of the study population was 49.03 ± 13.48 years. Only 12.5% of patients were aware of the diagnosis, treatment, and outcome. The study population consisted mainly of patients with chronic myeloid leukemia, colorectal carcinoma, breast carcinoma, and stomach carcinoma, which amounted for 78.3% of the study population. Bivariate analysis concluded that duration of treatment, adverse drug reaction (ADR), duration of oral anticancer drug intake in a month, coadministration with IV anticancer drugs, and frequency of drug intake (anticancer drug) were significant factors affecting drug adherence. Multivariate analysis of the above variables was insignificant, but ADR tended toward significance. Conclusion Drug adherence plays a major role in treatment outcome in cancer patients. ADR was independently associated with decreased drug adherence. Key interventions which should include counseling and behavioral modifications will reduce nonadherence.

The "collateral damage" of the war on COVID-19: impact of the pandemic on the care of epithelial ovarian cancer

The covid-19 pandemic has impacted the management of non-covid-19 illnesses. Epithelial ovarian cancer (EOC) requires long-duration multidisciplinary treatment. Teleconsultation and shared care are suggested solutions to mitigate the consequences of the pandemic. However, these may be challenging to implement among patients who come from the lower economic strata. We report the disastrous impact of the pandemic on the care of EOC by comparing patients who were treated during the pandemic with those treated in the previous year. We collected the following data from newly diagnosed patients with EOC: time from diagnosis to treatment, time for completion of planned chemotherapy, and proportion of patients completing various components of therapy (surgery and chemotherapy). Patients treated between January 2019 and September 2019 (Group 1: Pre-covid) were compared with those treated between January 2020 and December 2020 (Group 2: During covid pandemic). A total of 82 patients were registered [Group 1: 43(51%) Group 2: 39(49)]. The median time from diagnosis to start of treatment was longer in group 2 when compared to group 1 [31(23–58) days versus 17(11–30) days (p = 0.03)]. The proportion of patients who had surgery in group 2 was lower in comparison to group 1 [33(77%) versus 21(54%) (p = 0.02)]. Proportion of patients who underwent neoadjuvant (NACT) and surgery were fewer in group 2 in comparison to group 1 [9(33%) versus 18(64%) p = 0.002]. Among patients planned for adjuvant chemotherapy, the median time from diagnosis to treatment was longer in group 2 [28(17–45) days, group 1 versus 49(26–78) days, group 2 (p = 0.04)]. The treatment of patients with EOC was adversely impacted due to the COVID-19 pandemic. There was a compromise in the proportion of patients completing planned therapy. Even among those who completed the treatment, there were considerable delays when compared with the pre-covid period. The impact of these compromises on the outcomes will be known with longer follow-up.

Utility of ferritin and inflammatory biomarkers in the diagnosis of different stages of breast cancer

Objectives:

To assess the utility of ferritin and inflammatory biomarkers in the diagnosis of stages of breast cancer.

Methods:

The study consisted of 4 groups of 20 women, including the healthy control. The patients of group 1 comprised of stages I and II, group 2: stage III and group 3: stage IV of the disease. High sensitive C-reactive protein (hsCRP) and hepcidin were estimated by enzyme linked immunosorbent assay and ferritin by chemiluminescence immunoassay. The study was carried out in 2018 at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry-6, India.

Results:

The breast cancer disease progression correlated negatively with hemoglobin (Hb) (r= -0.6937, p<0.0001) and with ferritin levels, had a positive correlation (r=0.8444, p<0.0001). Ferritin negatively correlated with Hb among the subjects of the study (r= -0.6130, p<0.0001). Hepcidin correlated positively with hsCRP (r=0.998, p<0.0001). The ferritin/Hb ratio >3.9516 was used to identify the possibility of breast cancer utilizing the receiver operator curve values (area under curve [AUC]=0.997, sensitivity: 96.7, specificity:100). Ferritin values >103.4 were used to differentiate stage 4 from stage 3 of the disease (AUC: 0.893, sensitivity: 100, specificity: 85).

Conclusion:

Ferritin and ferritin/Hb are helpful in the differential diagnosis of stages of breast cancer.

Effect of cytotoxic chemotherapy on bone health among breast cancer patients. Does it require intervention?

BACKGROUND

Breast cancer (BC) is one of the most common malignancies worldwide. Although the burden and mechanisms of endocrine therapy-related bone loss are known, the evidence is scanty regarding the impact of cytotoxic chemotherapy on bone health. We have attempted to summarize the effect of cytotoxic chemotherapy on bone health in BC patients.

METHODS

A comprehensive literature search was performed via MEDLINE and Cochrane library databases to evaluate the effect of chemotherapy on bone health among women with BC. We included articles related to skeletal-related events, bone mineral density, bone turnover markers, osteoporosis-specific quality of life, bisphosphonate, and other bone-directed therapy. We excluded articles that included patients with metastatic breast cancer and patients receiving hormonal therapy.

DISCUSSION

Bone microenvironment in cancer is directly or indirectly influenced by clinical, hormonal, nutritional, and treatment factors. Calcitonin, parathyroid hormone, calcitriol, and estrogen are the major hormonal regulators. Bone turnover markers, namely bone formation and resorption markers, have been used to predict bone loss, fracture risk, and monitoring treatment response. Chemotherapeutic drugs such as anthracyclines and taxanes synergistically affect BMD and quality of life. Calcium, vitamin D, bisphosphonates, and denosumab are supplemented to prevent excess bone resorption. Bone-targeted anti-resorptive agents have been studied as potential anticancer agents in the adjuvant treatment of breast cancer.

CONCLUSION

This review summarizes the negative effect of chemotherapy on bone health of BC patients and the importance of preventing or treating bone loss.

Clinicopathological profile and its association with peritoneal disease among gastric cancer patients

BACKGROUND

There are no clinicopathological criteria or test to predict peritoneal metastasis either in primary or recurrent gastric cancer. The early prediction will help in altering or adding other adjuvant potential therapy modalities like HIPEC and maintenance chemotherapy.

METHODS

Paraffin based blocks of 110 gastric tumor specimens were subjected to IHC staining to assess VEGF, Her 2 neu, E cadherin, bcl 2 and p 53 expression and its association with peritoneal disease evaluated.

RESULTS

Her 2 neu uptake was present in 17.3%, bcl-2 expression in 19.1%, P53 expression in 40.9%, VEGF in 41.8% and E cadherin expression in 49.1% patients. On univariate analysis, a younger age(p = .029), female sex(p = .026), positive VEGF expression (p = .001) and p53 expression(p = .015) were significantly associated with peritoneal disease. A binomial logistic regression was performed to ascertain the effects of independent variables evaluated on univariate analysis. Of the 10 predictors variables, only three were statistically significant: tumor type, P53, and VEGF. Positive VEGF expression had 48.7, E cadherin 2.6 and Her2neu 1.5 times higher odds of exhibiting peritoneal disease.

CONCLUSION

A younger age, female sex, distal 2/3rd, diffuse variant, VEGF staining in >10% cells and decrease p53 expression were associated with peritoneal disease.

Epithelial Ovarian Cancer: Real-World Outcomes

Introduction Ovarian cancer is the third most common cancer and the second most common cause of death among gynecological cancers in Indian women. Ovarian cancer is heterogeneous, among them, epithelial ovarian cancer (EOC) is the most common. Primary cytoreductive surgery along with six to eight cycles of a combination of platinum and taxanes chemotherapy is the cornerstone of first-line treatment in EOC. This study was done to find clinicopathological factors affecting survival outcomes with first-line therapy in EOC in a real-world setting.

Objectives This study was aimed to find factors affecting progression-free survival (PFS) and overall survival (OS) with first-line treatment in EOC.

Materials and Methods We conducted a single-center retrospective study. We screened all the patients diagnosed with ovarian cancer from January 2015 till December 2019. We locked data in August 2019. Eligible patients were histologically confirmed EOC who underwent primary cytoreduction or received more than or equal to two cycles of chemotherapy or both. Patients who had received first-line treatment at another hospital were excluded.

Results Patients demographics and clinical characteristics: between January 5, 2015 to August 31, 2019, 435 patients with a diagnosis of ovarian malignancy were registered at our center. Among them, 406 (82%) had EOC, 290 (64%) newly diagnosed, and fulfilling eligibility criteria were included in the final analysis. The median age of the cohort was 53 years (range: 21–89 years) and 157 patients (54%) were >50 years of age (the Eastern Oncology Cooperative Group Performance status was ≥ 2 in 124 patients [43%]; median duration of symptoms was 3 months; and stage III/IV: 240 [83%]). Grading of the tumor was available in 240 patients of which 219 (91%) were of high grade. Subtyping was available in 272 patients (94%) of which the serous subtype was the most common constituting 228 patients (79%).

Treatment Most patients received chemotherapy (n = 283 [98%]) as the first modality of treatment (neoadjuvant/adjuvant and palliative). As neoadjuvant (NACT) in 130 patients (45%) and as adjuvant following surgery in 81 patients (29%). The most common chemotherapy regimen was a combination of carboplatin and paclitaxel in 256 patients (88%). Among 290 patients 218 (75%) underwent cytoreductive surgery. Among them, optimal cytoreduction was achieved in 108 patients (52%). Optimal cytoreduction rate (OCR) with upfront surgery and after NACT was 44 and 53%, respectively (Chi-square test: 0.86; p = 0.35).

Survival The median follow-up of the study was 17 months (range: 10–28 months) and it was 20 months (range: 12–35 months) for patients who were alive. At last, follow-up, 149 patients (51%) had progressed and 109 (38%) died. The estimated median PFS and OS were 19 months (95% CI: 16.1–21.0) and 39 months (95% CI: 29.0–48.8), respectively. On multivariate analysis, primary surgery (HR: 0.1, 95% CI: 0.06–0.21; p-value: <0.001) and early-stage disease (HR: 0.2, 95% CI: 0.1–0.6; p-value 0.04) were associated with superior PFS and primary surgery (HR: 0.1, 95% CI: 0.09–0.2; p-value: <0.001) was associated with superior OS.

Conclusion Primary surgery (upfront or interval) was associated with improved survival. Newer agents like bevacizumab, poly-ADP (adenosine diphosphate)-ribose polymerase inhibitors and HIPEC should be incorporated precisely into first line of therapy to improve outcomes.

Polymorphisms of T- cell leukemia 1A gene loci are not related to the development of adjuvant letrozole-induced adverse events in breast cancer

Letrozole, an aromatase inhibitor (AI), is the first-line adjuvant drug for treating hormone receptor-positive (HR+) breast cancer in postmenopausal women. However, harmful adverse events (AEs) and significant differences in drug response among individuals remain a significant problem in clinical application. Current evidence suggests that the observed individual variation in the treatment outcomes of AI is conferred by genetic variants. Hence, in this study, we examined the association of TCL1A gene polymorphisms with letrozole-induced AEs. The study subjects were postmenopausal HR+ breast cancer patients who were receiving adjuvant letrozole. Genomic DNA was isolated by a routine standard phenol-chloroform method. In total, 198 South Indian patients were genotyped for four single nucleotide polymorphisms (SNPs) in the TCL1A gene loci by the TaqMan allelic discrimination assay using the RT-PCR system. We used the odds ratio and 95% confidence interval to assess the genetic association. Musculoskeletal (MS) AEs and vasomotor symptoms (VMSs) are the most common side effects observed in the study cohort. Among 198 patients, 81 experienced musculoskeletal toxicity, reporting MS-AEs, 57 had VMSs, and 33 of them had both. The most frequently identified polymorphic variants in the patient series were rs11849538 (G), with an allele frequency of about 27.3%, followed by rs7158782-G (27.3%), rs7159713-G (25.8%), and rs2369049-G (22.5%). The genetic association analysis indicated no significant difference in the proportion of TCL1A gene variants between patients with and without AEs on either MS-AEs or VMSs. Though we observed high LD in all patient groups, the inferred haplotypes displayed a non-significant association with letrozole-induced specific AEs. However, the SNP functionality analysis by RegulomeDB provided a 2b rank score for rs7158782, suggesting a potential biological function. Our findings suggest that TCL1A gene polymorphisms may not play any role in the prediction of letrozole-induced AEs in South Indian HR+ breast cancer patients.

Frequency and risk factors of bleomycin-induced pulmonary toxicity in South Indian patients with germ-cell tumors

Aim

Bleomycin, etoposide, and cisplatin (BEP) regimen is the standard treatment for germ-cell tumors (GCTs). Bleomycin-induced pulmonary toxicity (BPT) is fatal and dose-limiting toxicity associated with this regimen. In this study, we aimed to identify the frequency and risk factors of BPT in South Indian GCT patients receiving BEP regimen.

Patients and Methods

The study was carried out in the Department of Medical Oncology, Regional Cancer Centre at a tertiary care hospital in South India. All the patients with GCT (testicular and ovarian) who were receiving BEP regimen from December 2014 to May 2018 were included in the study. BPT was defined as the presence of radiological features and/or clinical symptoms during or post-treatment.

Results

BPT was observed in 11 (27%) patients of 41 analyzed patients. Five (12%) patients developed BPT during treatment whereas six (15%) patients developed BPT post-treatment. Cumulative bleomycin dose ≥240 mg (relative risk 3.8, confidence interval: 1.2-12.2,P =0.02) was found to increase the risk of BPT. Three-year overall survival in patients with and without toxicity was 82% and 93%, respectively.

Conclusions

The frequency of BPT in the study population is 27%, and cumulative bleomycin dose ≥240 mg has been found to be associated with increased risk of developing BPT. BPT does not negatively impact survival outcome in GCT patients receiving BEP regimen.

Efficacy and safety of capecitabine and oxaliplatin (CAPOX) treatment in colorectal cancer: An observational study from a tertiary cancer center in South India

Background

5-fluorouracil (5-FU) was the standard treatment care for colorectal cancer (CRC), however, its efficacy was limited due to safety concerns. Capecitabine and oxaliplatin (CAPOX) treatment was found equivalent to 5-FU in efficacy and preferred now due to easy management and convenience in administration. Hence, the present study aims to determine the efficacy and safety associated with CAPOX treatment in a real world non clinical setting.

Methods

145 treatment-naive and newly diagnosed CRC patients were recruited in the study. Each patient received oxaliplatin 130 mg/m² infusion over 2 hours on day 1 and oral capecitabine 1000 mg/m² in divided doses twice daily for the next 14 days of a 21-day cycle.

Results

In the adjuvant setting, the observed disease-free survival rate was 62% (n=34) in the colon and 67% (n=15) in the rectum cancer patients at 2 years. The observed overall survival rate in the colon and rectal cancer was 80% (n=44) and 83% (n=18) respectively at 2 years. In the palliative setting the observed progression-free survival rate was 28% (n=13) in the colon and 33% (n=7) in rectal cancer patients at 2 years. The observed OSR at 2 years was 64% (n=30) in the colon and 67% (n=14) in the rectal cancer patients. Thrombocytopenia (17, 11.7%) and diarrhea (8, 5.5%) were the most commonly observed grade 3/4 hematological and gastrointestinal toxicities. Hand-foot syndrome and peripheral neuropathy were the major contributors for dose reduction (14, 9.6%), treatment delay (8, 5.4%), and drug discontinuation (9, 6.1%) in the study cohort.

Conclusion

CAPOX treatment was found to be effective but associated with several dose-limiting toxicities.

Embryonal rhabdomyosarcoma of breast, pleura, and retroperitoneum diagnosed from pleural fluid cytology

Embryonal rhabdomyosarcoma (ERMS) is a malignant small blue round cell tumor which is commonly seen in head and neck region. Breast and pleural involvement are uncommon. Rhabdomyosarcoma has been rarely reported in the body fluids like ascitic, pleural, and cerebrospinal fluid. In this article, we report an interesting case of ERMS which had deceptive small blue round cells in pleural fluid. The cytomorphological features along with a panel of immunocytochemical markers helped in arriving at the definite diagnosis. Later, biopsy from the breast lump and retroperitoneal mass also revealed the same tumor. This case is reported since it is rare to find sarcoma cells in pleural fluid and highlight the diagnostic difficulties faced during interpretation.

Level of Anxiety and Depression and Its Clinical and Sociodemographic Determinants among the Parents of Children with Cancer Undergoing Chemotherapy

Objective  The aim of this study was to find the level of anxiety and depression and its clinical and sociodemographic determinants among the parents of children with cancer on chemotherapy.

Materials and Methods  Hamilton-A (HAM-A) and Hamilton-D (HAM-D) scales were used to assess anxiety and depression, respectively, in this cross-sectional study. The assessed parents were administered the questionnaire along with collection of sociodemographic and clinical data through a structured data collection proforma between August 2018 and November 2018.

Statistical Analysis  The sociodemographic factors and the clinical characteristics were analyzed and have been expressed descriptively and associations between the sociodemographic characteristics, clinical characteristics of the children, and the calculated scores obtained from HAM-A and HAM-D scales were analyzed using chi-squared test. A p -value of <0.05 was considered statistically significant.

Results  Out of 101 parents, 86 (85.14%) were found to have a mild, moderate, or severe depression score. Parents of children with solid tumors undergoing chemotherapy had higher frequency of severe and very severe depression. Majority of the parents (56.4%) assessed with HAM-A scale had mild level of anxiety that was significantly affected by the level of education.

Conclusion  This study confirmed a very high frequency of depression and anxiety in the parents of children affected with cancer undergoing chemotherapy. Type of cancer (solid or hematological) was found to be a predictor of depression, while education level was found to be a predictor of anxiety in the parents.