Clinical and histopathological spectrum of cranial small round cell tumors: An experience from a tertiary care center

BACKGROUND

Small round cell tumors (SRCTs) are a group of malignant neoplasms with minimal or no differentiation, characterized by the presence of round cells with high nuclear-cytoplasmic ratio. Although SRCTs can occur in any part of the body, involvement of central nervous system (CNS) is uncommon.

AIM

We aimed to study the clinicopathological spectrum of cranial SRCT diagnosed in our institute over a period of four years (2016-2019).

MATERIAL AND METHODS

A retrospective review of medical records (2016-2019) with a morphological diagnosis of cranial SRCT was made. Both intra-axial and extra-axial tumors were included. A total of 60 cases were retrieved, and the clinical and histopathological features were studied. Special cytochemical staining and immunohistochemistry were performed, where needed.

RESULTS

The mean age at presentation was 18.4 years (range, 1-60 years), with a male-to-female ratio of 2.5:1. The most common site was posterior fossa of brain (n = 28, 47%), followed by dorso-lumbar spine (n = 9, 15%). The most common type of tumor was medulloblastoma (n = 29, 48.3%), followed by Ewing sarcoma (ES)/peripheral primitive neuroectodermal tumor (pPNET) (n = 11, 18.3%), non-Hodgkin lymphoma (NHL) (n = 9, 15%), neuroblastoma (n = 3, 5%), and CNS embryonal tumor, NOS (n = 2, 3.3%). One case each of atypical teratoid rhabdoid tumor (ATRT), rhabdomyosarcoma, pineoblastoma, melanoma, rhabdomyosarcoma, and undifferentiated pleomorphic sarcoma was also documented.

CONCLUSIONS

SRCTs have a variable age of presentation. Their incidence in CNS is low as compared to other organ systems. On light microscopy, the histopathology of these lesions is overlapping, posing a great diagnostic dilemma for the pathologist. The use of ancillary techniques like immunohistochemistry helps in arriving at the correct diagnosis. Treatment strategy and tumor prognosis also vary along the entire spectrum of SRCT, thus making exact characterization essential for proper management.

Multiple Sessions vs. Single Session Image-Based Intracavitary Brachytherapy for Locally Advanced Cervical Cancer: A Randomized Control Trial

PURPOSE/OBJECTIVE(S)

The objectives of this study are: 1) To compare the acute toxicity caused in the treatment of locally advanced cervical cancer (LACC) treated with weekly multiple applications vs. a single application for image-guided intracavitary High Dose Rate (HDR) brachytherapy (BT) after External Beam Radiation Therapy (EBRT) 2) To compare the loco-regional control of cancer at six months in the two arms MATERIALS/METHODS: In a prospective study, 40 patients with biopsy-proven LACC with FIGO-2018 stage IIB-IIIC1 disease, underwent EBRT to the pelvis at a dose of 50.4 Gy/ 28 fractions over 5.5 weeks with weekly concurrent cisplatin. After completion of EBRT, they were randomized into two arms with 20 patients each. In the Control arm (Arm-A), BT sessions were given with weekly 3 applications whereas, in the experimental arm (Arm-B), all the sessions were given with a single application at 6-12 hours intervals with aim of the high-risk clinical target volume receiving >80 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving <85 Gy and <75 Gy, respectively. The OAR contouring was done on CT RESULTS: All 40 patients were treated as per protocol. The mean duration of treatment including EBRT and BT was 73.15 days [95% CI 68.63-77.66] in Arm A and 55.85 days [95% CI 52.11-59.58] in Arm B which was significant. After 6 months, 37 patients came for follow-up, all 19 patients in Arm A had Grade 1 or Grade 2 rectal toxicity. In Arm B as well all 18 patients had Grade 1 or Grade 2 rectal toxicity. Bladder toxicity was Grade 1 or Grade 2 in 18 patients and Grade 3 severity in 1 patient among Arm A. Among 18 patients of Arm B, bladder toxicity of Grade 1 or Grade 2 was seen in 16 patients, and 2 patients had grade 3 toxicity. 2 patients in Arm A and 3 in Arm B complained of Grade 1 urinary incontinence. Moreover, Abdominal pain at 6 months was of Grade 1 in around 6 patients in Arm A but 14 patients had abdominal pain in Arm B which was of Grade 1 in 8, 4 had grade 2 and 2 patients had grade 3 severity abdominal pain. In the monthly analysis of acute toxicity, none of the patients showed Grade 3 or 4 toxicity at the 1st, 2nd, or 3rd month of completion of treatment. When comparing local control in both arms at 6 months, 2 patients had treatment failure in the Experimental Arm compared to only 1 patient in the Control Arm CONCLUSION: Single Application Multiple Fraction Intracavitary Brachytherapy post concurrent CTRT is a safe option for the treatment of locally advanced cervical cancer. When compared to the weekly application arm, single-application ICRT showed a comparable acute toxicity profile and comparable local control rates as well. Some patients in Single Application Arm showed abdominal pain which needs to be investigated with further trials. The overall treatment time in the single application arm is significantly lower than the standard weekly application arm.

Home Care of Patients with Head Injury: Are We Neglecting the Caregivers?

In the absence of professional long-term care facilities in India, home care to patients with head injury is usually provided by family members. In this scenario, the mental health of the caregivers remains an important issue. This factor is constantly neglected by the health care providers and the society alike. With the result, the caregivers are prone to depression, anxiety, and other forms of mental illnesses. This also has a negative impact on the recovery and rehabilitation of the head injury survivor. In this article, the authors have reviewed relevant literature to find out the extent and prevalence of this problem among home caregivers of patients with head injury. The authors have also highlighted the possible measures that the treating neurosurgeon and the society can take for effective management of these issues. Their aim is to make the neurosurgeon and other health care providers aware of this issue and its various ramifications.

P53 and Ki-67 Expression in Primary Pediatric Brain Tumors: Does it Correlate with Presentation, Histological Grade, and Outcome?

Context:

Pediatric brain tumors are a vexing problem for the neurosurgeon due to the fragile patient cohort. We attempt to find parameters which can help us to treat and prognosticate these patients in a better way.

Aims:

This study aims to correlate clinical presentation, outcome, and histological grade with P53 and Ki-67 expression in primary pediatric brain tumors.

Setting Design:

This was a prospective, observational study.

Patients and Methods:

Forty-seven patients with primary brain tumors in the age group 0–18 years were included in this study. Clinical presentation was noted. Patients were operated, and specimen was sent for histopathological and immunohistochemistry examination for p53 and Ki-67. The WHO classification of 2007 was used to grade the tumors. Follow-up was done at 3 and 6 months with Glasgow outcome score. Expression of p53 and Ki-67 in different tumors was correlated with clinical presentation, tumor grade and outcome.

Analysis Method:

Statistical Package for Social Science version 17. P < 0.05 was considered statistically significant.

Results:

There was statistically significant correlation between high tumor grade and high Ki-67 levels (P = 0.000). On post hoc analysis, there was a significant difference between p53 levels in Grade 1 and Grade 4 tumors. There was statistically significant correlation between neurological deficit and higher p53 levels (P = 0.040). There was statistically significant correlation between poor outcome and higher p53 (P = 0.034) and Ki-67 (P = 0.000) levels at 3 months follow-up which continued at 6 months.

Conclusions:

From this study, we conclude that p53 and Ki-67 expression in pediatric brain tumors is associated with poor outcome and correlates with tumor grade. Moreover, p53 expression correlates with neurological deficit.

Epilepsy surgery in a pediatric population: a retrospective study of 129 children from a tertiary care hospital in a developing country along with assessment of quality of life

PURPOSE

To assess the outcome of a pediatric population operated for drug-resistant epilepsy from a large tertiary care center in India.

METHODS

Retrospectively: quality of life (QOL); prospectively: preoperative assessment included interictal EEG, MRI (as per epilepsy protocol), video-EEG. Ictal SPECT (with subtraction) and PET were performed when required. QOL scores were assessed using the HASS or SSQ for seizure severity, Quality of Life in Childhood Epilepsy (QOLCE) for QOL, and Child Behavior Check List (CBCL) for behavior.

RESULTS

142 were operated from January 2000 to June 2011 by the senior author. 118 patients with at least 1 year of follow-up were included in the study. Mean age at surgery was 9.8 ± 4.3 years. In addition, 40 patients underwent QOL assessment prospectively both before and after surgery. Mean duration of epilepsy was 5.3 ± 3.3 years. A class I outcome (Engel's) was seen in 79.5% patients, class II in 8.6%, class III in 10.7%, and class IV in 1 patient. As per surgical procedures, class I outcome in patients who underwent temporal resection, hemispherotomy and extratemporal resection was 76, 87 and 72%, respectively. QOL scores correlated with duration of seizures, epileptic encephalopathy and outcome of surgery, but not with side of surgery, age and sex.

CONCLUSIONS

This study, the largest reported from India, has demonstrated satisfactory results for epilepsy surgery in children.