|Issue No. 22 - Sep 2016|
|Switch Maintenance Tyrosine Kinase Inhibitors in EGFR Mutation Positive Metastatic Non-squamous NSCLC: Experience from the real world|
A. Pandey, V. Noronha, A. Joshi,
Tata Memorial Hospital, Parel, Mumbai, India
Induction pemetrexed platin doublet is
the standard of care in locally advanced
and metastatic non squamous NSCLC.
Maintenance TKI has been successfully
explored to sustain benefit achieved
after induction therapy especially in
EGFR mutation positive NSCLC. The aim of
this study is to evaluate outcomes with
maintenance TKI in EGFR mutation
positive metastatic non squamous NSCLC
after induction pemetrexed-platin
doublet. The objective is to calculate
progression freesurvival rate, overall
survival rate and factors affecting
Material and Methods: Data of patients with locally advanced and metastatic non squamous NSCLC who received induction pemetrexedplatin doublet and later went on to receive maintenance TKI in view of EGFR mutation positive (N=80) were retrieved from prospectively maintained lung cancer database registered between June 2011 till March 2014. Kaplan Meir survival analysis was used for progression free survival and overall survival. Log rank test was used to evaluate factors affecting outcome.
Result: Median follow up is 19 months. Out of 80 EGFR mutation positive patients, 35 patients (44%) achieved partial response while 45 (56%) had stable disease after six cycles of induction pemetrexed platin doublet. Gefitinib was the most common TKI used in 54 patients (67%) compared to erlotinib in 26 patients (33%) as maintenance therapy. Median Progression free survival and overall survival are 11 months and 22 months respectively. Patients receiving maintenance TKI after partial response to induction chemotherapy have superior survival compared to patients who had stable disease after induction chemotherapy. (25 months Vs 20 months; p=0.01)
Conclusion: Use of maintenance TKI after induction chemotherapy delays disease progression and improves survival in EGFR mutation positive NSCLC. Patients achieving partial response compared to stable disease with induction chemotherapy have superior outcomes with maintenance TKI.
|11-15||Primary Thyroid Lymphoma: Clinicopathologic Characteristics and Therapeutic Outcomes of Six Cases in Morocco|
H. Kloub, N. Salmi, H. Mrabti, H.
Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
non-Hodgkin lymphomas of the thyroid are
uncommon and account for 1-5% of all
thyroid malignancies and less than 2% of
extranodal lymphomas. The aim of the
present study was to review our
experience and management of primary
thyroid lymphoma and to discuss the
diagnostic and therapeutic
Methods: All non-Hodgkin lymphoma diagnosed at our institution between 2007 and 2011 were reviewed, six cases of primary thyroid lymphoma were identified. The clinical and pathological features of these patients were analyzed.
Results: There were five females and one male and their mean age was 67.5 years. All patients presented with an enlarging anterior neck mass and two patients also have compressive symptoms. Five patients have a history of pre-existing goiter, four have ‘B’ symptoms and one was hypothyroid. All patients have B-cell Non Hodgkin Lymphoma. Four patients have stage II disease, while two patients have disseminated disease. All patients underwent thyroid resection. One patient died after surgery. The five others were treated postoperatively with 3-weekly cycles of combination chemotherapy. One patient in stage II received consolidation radiotherapy after chemotherapy. Complete remission was achieved in four patients and one patient had partial response to the treatment. After a median follow-up of 26 months (2-51), three patients are still alive without any relapse, one died and the last was lost to follow up.
Conclusion: Primary thyroid lymphomas are rare. Treatment depends on the histological subtype and stage of the disease, including radiotherapy and chemotherapy. The prognosis usually is favorable with proper treatment.
|16-20||Evaluation of Clinicopathological Findings on 255 cases of Inoperable Locally Advanced Breast Carcinoma: A Tertiary Care Experience|
cancer is the second most common cancer
in the Indian female population. LABC
and metastatic breast cancer are the
most common stages at presentation in
most low-resource countries. Although
the incidence of LABC has decreased
significantly in countries with enhanced
resources thanks to widespread education
and screening programs, it remains a
daily encounter for surgeons and
oncologists in low-resource countries.
Neoadjuvant therapy has been studied
widely for the treatment of LABC and is
followed by locoregional therapy.
Objectives: As per our hospital data, breast cancer is also found to be the second leading malignancy in women and locally advanced breast cancer is the most common type of breast cancer. Hence, we undertook this study to evaluate the clinical profile, histopathologic types and grade of the disease in our patients.
Materials and Methods: This study was undertaken over a period of three years comprising of 255 patients who underwent modified radical mastectomy following neoadjuvant chemotherapy after preliminary diagnosis of carcinoma on histopathological examination of the trucut biopsy specimens. Clinicopathological evaluation was done in all of these cases following standard protocols.
Results: The study comprised of 252 female patients and 3 male patients in the age range of 26 to 70 years. Majority (255, 66.6%) of the cases were within the age range of 31‑60 years. Three females had bilateral breast cancer. Invasive ductal carcinoma no special type was the most common histopathologic pattern, and was seen in 254 (98.4%) cases. Most tumors were Scarff Bloom Richardson grade II and American Joint Committee on Cancer pathologic stage 3.
Conclusions: The present study has provided information about the clinicopathological aspects of locally advanced breast cancer in patients who are from rural areas. LABC remains a daily encounter and challenge for medical and surgical oncologists in developing low-resource countries. Neoadjuvant chemotherapy is recommended for inoperable LABC at all resource levels.
|21-25||Effect of Cancer Awareness on the Percentage of Reported Oral Cancers in Aden, Yemen|
Aden University, Yemen
|Background: From the
start of Al-Amal Oncology Unit
Foundation in Aden (2007), the awareness
programs commenced and continued to
widen the campaign on targeted
population (male and female) in schools,
colleges, mosques, private and
government offices, local radio and
television broadcasts. This study aimed
to measure the impact of cancer
awareness vis-à-vis the number of
reported cases of cancers in Al-Amal
Oncology Unit in Aden using oral cancer
as the focus of study.
Methods and Resources: This study was conducted retrospectively for three years (2008-2010), using the data from the archives of Al-Amal Oncology Unit in Aden, Yemen. The records of 41 newly registered oral cancers were thoroughly reviewed and analyzed in comparison with the total newly registered cancers over the same period of time.
Results: It was found that the percentage of oral cancers during the time of intensified regular awareness activities was not significant after one year; however, there was a significant increase at the end of 2010. Results also show that females showed higher percentage of reported oral cancers after intensified regular awareness activities covering a wider age range. The percentages of operable (early stages) oral cancers were markedly increased after cancer awareness activities were implemented, from 8.3% in 2008 to 60.0% in 2010.
Conclusion: Cancer awareness aims to minimize late presentation of the disease and encourages early presentation and detection to improve survival rates. This study concluded that an improved cancer awareness program marked a significant improvement on patients’ diagnosis due to earlier presentation and thus improves the chances of survival. Cancer awareness should continue as a regular activity in Aden, Yemen to sustain this improvement so far.
|26-36||Population Pharmacokinetics of Imatinib and its application to the therapeutic drug monitoring: Middle East CML population|
M. Ansari1, B.
N. Mosavi5, E. Mohajeri1
Despite the outstanding results
generally obtained with Imatinib in the
treatment of chronic myeloid leukemia,
some patients show sub-optimal or no
response. To evaluate the relationship
between steady-state trough plasma
concentration and clinical response in
CML patients. The objectives of this
study were to assess the variability in
Imatinib pharmacokinetics and to explore
the effects of several demographic and
biological covariates on the disposition
Methods: A population pharmacokinetic analysis was performed on 170 plasma samples from 74 adult Iranian chronic myeloid leukemia patients. A population pharmacokinetics model was developed to evaluate the influence of covariates on clearance and volume of distribution.
Results: A one-compartment model with first-order absorption appropriately described the data, giving a mean (±SEM) clearance of 14.3l (±1.0) and a volume of distribution of 347 l (±62). Clearance was influenced by body weight, age and gender. By considering these covariates the interindividual variability decreased from 47% to 19%. A large proportion of the interindividual variability (19% of clearance and 45% of volume of distribution) remained unexplained by these demographic covariates.
Discussion and Conclusion: By considering morphological and biological covariates, a unique covariate model could be used to accurately describe Imatinib pharmacokinetics in our population and because of the pharmacokinetic variability of Imatinib and the reported relationships between its plasma concentration and efficacy and toxicity, the usefulness of therapeutic drug monitoring as an aid to optimizing therapy should be further investigated.
|37-42||Does Alternative and Traditional WASAM (Local cautery) Therapy Facilitate an Early and More Extensive Locoregional Metastasis of Breast Cancer?|
I. Mehdi, B. Al Bahrani, K. Al-Harsi, S.
Al Rahbi, D. Varvaras
large heterogeneous group of unproven
remedies exist to treat cancer in both
developed and developing countries. Some
of these remedies often do more harm
than good to the patients. The
traditional medicine is the sum total of
the knowledge, skills, and practices
based on the theories, beliefs, and
experiences indigenous to different
cultures. The traditional medicine in
Oman is based on herbal treatment and
skin treatment (massage, Cupping and
skin burn “cautery” treatment-known as
Wasam or Kaiy). WASAM (local cautery) is
widely practiced in Oman for treating
cancer. The loco-regional spread of
breast cancer depends on numerous
factors like tumour size, grade,
receptor status, Ki67, Lympho vascular
invasion, location of tumour within the
breast, multifocal tumour, depth of
tumour from skin, and status of
local/regional lymphatic drainage.
Objective: The objective of study was to analyze the frequency of loco-regional spread in female breast cancer patients who received Wasam therapy.
Patients and Methods: It is a retrospective analysis of female breast cancer cases diagnosed between 2008-2014 at the Department of Surgery and National Oncology Center, the Royal hospital who were treated with Wasam therapy. Breast cancer patients’ data were retrieved and reviewed from Electronic medical record system (EMR AL-SHIFA). The tumour (T) stage and Nodal (N) status were analyzed in all patients. The data of patients who received Wasam was compared with those who did not receive it as controls.
Results: A total of 532 cases were diagnosed to have breast cancer during the study period, of which 464 were included in this analysis. Out of these 74 have Wasam and 390 were in control group not receiving any Wasam therapy. No Wasam patient had N0 status while more than one third of the control group was N0. About 15.9% (74/464) had Wasam therapy. It was found that 6.7%, 67.6% and 25.7% had one, 2-5 and more than 5 scars of Wasam therapy respectively. These patients underwent surgery (either mastectomy or breast conserving) with pathologic analysis of tumour and axillary lymph nodes (sentinel nodes, sampling or clearance). Approximately 50% of tumours were less than T2 stage. All 74 patients (100%) who received Wasam therapy showed axillary lymph node metastasis (N1 to N3), irrespective of their T stage (size of tumour). Further analysis is under way of these cases to look into additional risk factors like tumour grade, ER, PR, Her-2, Ki67, LVI, and location of these tumours within the breast.
Discussion: The tumour size (T stage) is an important predictor of locoregional spread. Published data suggest the frequency of axillary nodal metastasis are as: T1a 4.2%, T1b 7.4%, T1c 15.8%, T2 28.7% and T3 26.2%. The Grade I, II, and III have 22.1%, 51.6%, and 26.3% chances of axillary LN metastasis. ER+ve tumours have 38.9% and ER-ve tumours have 8.4% frequency of metastasis to axillary LNs. The data from our study suggest that the Wasam cases have higher and early loco-regional spread of breast cancer (100% vs. 19.2% in T1, 100% vs. 50% in T2, and 100% vs. 90% in T3). The Wasam therapy can set in local inflammation or infection. This can cause increased local temperature and oedema. This may well facilitate lymph angiogenesis and dilatation of existing channels.
|43-46||Ring chromosome may signal progression of Fanconi anemia|
I. F. Elmula3
1 Dept. of Hematology, Faculty of Medicine and Health Sciences, Kordofan University, Sudan.
2 Dept. of Pediatric Endocrinology, Gaffer Ibnaof Pediatric Hospital, Khartoum-Sudan.
3 Dept. of Clinical Genetics, Assafa Academy, Khartoum-Sudan
Background: Fanconi anemia (FA) is a
genomic instability disorder associated
with high risk of AML. Ring chromosomes
are results of genomic instability and
observed in many human neoplasias. The
present study aimed to assess the role
of ring chromosome in the progression of
Material and Methods: The study included 60 patients with provisional diagnosis of FA. A total of 5 ml of venous blood was collected and processed for complete hemogram, peripheral blood film, and breakage test. Patients with positive breakage test were followed-up every 3-months interval for a maximum of 24 months. Subsequently, 2 ml of BM aspirate was collected to determined BM morphology, and cytogenetic analysis.
Results: Of the 60 patients, 21 (35%) showed positive breakage test including ring chromosome in 4 (19%) patients. During the follow-up of the 21 FA patients, the 4-patients with ring chromosome developed AML within the interval of 8-14 months. However, another patient without ring chromosome developed AML after 23 months of the diagnosis. BM analysis showed non-random clonal chromosomal abnormalities such as del (20) (q11) in 3 cases; add(1)(q12); -7, -8, and +9 in one case each. Normal karyotype was seen in the 5th patient without ring chromosome.
Conclusion: The present study suggested that the ring chromosome formation in FA may single the progression of the disease. Thus, early BM transplant for patients with ring chromosome is crucial to avoid the development of AML.
|47-50||Assessment of hypoxic stress in 44 women with breast cancer in the West Algeria|
F.Z. El Kebir1
|Aim: The objective
of this study was to evaluate the
expression of hypoxia-inducible
transcription factor 1α (HIF1α) protein
profile among women with breast cancer
in a population of western Algerian and
to correlate the intensity of this
expression with prognosis histological
grade Scarff Bloom and Richardson (SBR)
of the disease and the age of the
Methods: We used a kit provided by Life Science Inc (UScnk) for a sandwich enzyme immunoassay for the quantitative measurement of in vitro HIF1α in plasma in 44 patients and 44 controls in a population of western Algerian. Then we looked for the correlation between the intensity of the expression of HIF1α and prognosis histological grade SBR and the age of the patients studied.
Results: The results indicate high levels of HIF1α at SBRIII grade with an average value of 12.26 ± 0.5 ng/ml. The average age of patients is around 50 ± 1year. In healthy subjects the mean concentration of 1.88 ± 0.1 ng/ml represents HIF1α with a mean age of 49 ± 1year.
Conclusion: Clinical monitoring of patients treated for breast cancer by assaying the HIF1α marker seems to be very important in the prognosis.
|51-54||Neo-adjuvant Chemotherapy in Locally Advanced Breast Cancer: A Retrospective Analysis from Tertiary Care Centre|
Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
cancer is the most common cancer in
women in India. The incidence of LABC is
30%-40% in developing countries as
compared to developed countries, lack of
awareness and screening programmes in
developing countries are supposed to be
main contributor of this increase
incidence. The use of neoadjuvant
chemotherapy in locally advanced breast
cancer has shown benefits in down
staging of tumors, and increases the
rate of breast conserving surgeries.
Aim: The aim was to compare response rate (clinical and pathological), the disease free survival, and overall survival in two chemotherapy regime.
Methods: Medical records of 415 patients diagnosed with invasive breast cancer were analysed. One hundred and seventy five patients received neo-adjuvant chemotherapy. They were divided in two groups, sequential therapy with 4 cycles of anthracycline followed by 4 cycles of docetaxal were in group 1 as compared to those who received anthracycline based chemotherapy were allocated in group 2.
Results: Sequential NACT with AC-D showed better disease free survival and overall survival in comparison to anthracycline based NACT.
Conclusion: Locally advanced breast cancers have shown good response with taxane based sequential chemotherapy.
|55-60||Chemoradiation for organ preservation in the treatment of muscle invasive bladder cancer: Our Institutional Experience|
1 Dept. of Radiation Oncology, 2 Dept. of Surgical Oncology, 3 Dept. of Urology, 4 Dept. of Medical Oncology,
Max Super Speciality Hospital, Vaishali, Ghaziabad U.P. India
|Aim: To assess
outcome of chemoradiotherapy for organ
preservation in muscle invasive bladder
Material and Methods: 41 patients treated between January 2010 to January 2015 were evaluated in the present study. All patients T staged ranging from cT2-T4a and had undergone maximal transurethral resection of bladder tumour (TURBT). After maximum bladder tumour resection patients were treated with Radiotherapy with or without concurrent chemotherapy. 8 weeks after completion of treatment response was assessed by check cystoscopy, urine cytology and CECT scan Abdomen. Data regarding the toxicity profile, initial complete response rates at 3 months, occurrence of loco regional or distant failure and survival was recorded.
Results: Age ranged between 45- 84 years, (mean age 65.44). Radiotherapy dose planned ranged from 60 Gy/30fr to 70.3 Gy/37 fractions to primary target and 59.2 Gy/37fractions to the nodal disease. PTV volume ranged from 69-548.9 cc. 23 patients received concurrent chemotherapy weekly. 11 patients have cystitis (5 Gr 1, 4 Gr II and 2 Gr III). 5 patients have myelosuppression. 10 patients have acute gastrointestinal toxicity (5 Gr-I, 4 Gr-II, 1 Gr-III). At the time of analysis follow up ranged from 3–42 months (median follow 1 year).The DFS at 42 months was 54%. Out of 39 patients 3 were lost to follow up (2 in partial bladder group and 1 in whole bladder group). Out of 36 patients 24 (66.6%) are disease free, 4 (11.1%) patients had recurrence for which 2 underwent salvage cystectomy whereas 2 patients received palliative chemotherapy. Five patients developed distant metastases (4 bone and 1 brain metastasis).
Conclusion: Bladder-preservation therapy for muscle-invasive bladder cancer is a valid substitute in selected cases with long-term efficacy similar to radical cystectomy, with the additional advantage of preserving excellent bladder function in the majority of long-term survivors.
|61-63||Unusual Destruction of the Nasal Septum|
E. El Rassy1,
1 Hematology-Oncology Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
2 Radiology Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
|Extranodal Natural Killer/T-cell lymphoma (ENKTL) is the most common cause of nasal cell lymphoma. It manifests by progressive destruction of the facial midline features with nasal obstruction and local destruction of soft tissue. Therefore, establishing the diagnosis of this disease tends to be difficult. This is attributed to an extensive differential diagnosis of infectious, autoimmune, neoplastic and inflammatory etiologies. We herein report the case of a 63-year-old female who presented to our department for persistent nasal congestion resistant to symptomatic treatment that was found to have an ENKTL. In this paper, we discuss the pathogenesis, clinical and imaging findings, differential diagnosis, prognosis and treatment.|
|64-68||GIST: Institutional Experience at SRMS-IMS, India|
1 Dept. of Surgical Oncology, 2 Dept. of Interventional Radiology, 3 Dept. of Pathology,
SRMS-IMS, Bhojipura, Bareilly, India
|Gastro-Intestinal Stromal Tumors (GIST) is a malignant, non-epithelial, mesenchymal tumor of the digestive tract that is not uncommon in clinical practice nowadays; diagnosis being based upon immuno-histo-chemical analysis of the resected or biopsied (FNAC) specimen. Abdominal lump with or without intra-luminal bleed is a common mode of presentation. Early diagnosis and appropriate management with surgery and/or Imatinib therapy improves recurrence free survival and may impact overall survival. We present here our institutional experience of four patients, admitted in Onco-Surgery Dept., with pain abdomen and upper/lower gastrointestinal bleed, which, on subsequent workup were diagnosed to be cases of GIST, were appropriately managed according to their disease stage and show recurrence-free survival on follow-up.|
|69-71||Metastatic Ameloblastoma to Brain: A Rare Entity|
1 Departments of Neurosurgery, 2 Pathology and 3 Surgical Oncology,
Sheri-Kashmir Institute of Medical Sciences, Kashmir, India 190011
|Ameloblastoma is a rare odontogenic tumor of the jaw. It is a benign neoplasm but local recurrence is common. Metastasis from this tumor is all the more rare. The commonest site for metastasis is lung. Brain is a very uncommon site of involvement. Overall prognosis is good. We hereby discuss ameloblastoma of lower jaw in a young adult which had metastasized to brain. Patient was operated for the metastatic lesion of brain and is doing well on follow-up.|
|72-75||Moderately Differentiated Neuroendocrine Cell Carcinoma of the Vulva: A Case Report and Review of the Literature|
1 Iran University of Medical Sciences, Firoozgar Hospital, Tehran, Iran.
2 Department of Information Technology, Tarbiat Modarres University, Tehran, Iran.
3 Department of Obstetrics and Gynecology, Firoozgar Hospital, Tehran, Iran
|Primary vulvar neuroendocrine carcinoma are extremely rare. There have been few cases of these tumors most of which have been considered as Merkel cell carcinoma. This report describes a moderately differentiated neuroendocrine cell carcinoma that was not compatible to any of previously reported cases. The patient underwent left hemivulvectomy and bilateral inguinal lymph node dissection. Pathology examination revealed a 5×5 cm mass with no lymph node involvement. Post-op evaluation ruled out any regional and distant metastasis and thereby did not receive chemotherapy or radiotherapy. Four years of close follow up evidenced no signs of recurrence, regional involvement or distant metastasis.|
|76-79||Acute lymphoblastic leukemia mimicking Wilms tumor at presentation|
1 Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, New Delhi.
2 Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
lymphoblastic leukemia (ALL), the
commonest malignancy of childhood, is
known to manifest with a myriad of
atypical presentations. Nephromegaly is
a rare presentation of childhood ALL
with hepatic mass being even rarer.
Case Presentation: We present a 3 year-old child with unilateral renal mass and hepatic mass lesion with normal blood counts, initially suspected to have metastatic Wilms tumor based on clinical, radiological and WT1 positivity on immunocytochemistry of renal mass. He was later diagnosed as ALL with peripheral blood flowcytometry and bone marrow examination.
Discussion: Renomegaly at presentation of acute leukemia is not necessarily due to leukemic infiltration and rarely leads to renal impairment. The radiological differential of such a renal mass includes both benign and malignant entities including metastasis. Over-expression of WT1 mRNA has been found in a number of solid tumors and hematological malignancies and is far from being diagnostic of Wilms tumor. Again, a small number of children with acute leukemia may have a deceptively normal complete blood count at presentation. Though, initial all (clinical, radiological, hematological, and immunocytological) parameters pointed towards a diagnosis of Wilms tumor in our case, the subsequent development of thrombocytopenia and lymphocytic leukocytosis prompted further investigation and final diagnosis of ALL.
Conclusion: WT1 positivity is a known phenomenon in childhood ALL and undifferentiated lymphoblasts may be positive for WT1 and negative for Leucocyte common antigen. Acute leukemia with renal and hepatic mass with normal blood counts at presentation is a diagnostic challenge.
|80-89||The Pathophysiologic Basis of Anaemia in Patients with Malignant Diseases|
1 Department of Paediatrics, 2 Department of Haematology
Aminu Kano Teaching Hospital, PMB 3452, Kano, Nigeria.
|Cancer patients frequently present with anaemia that may result from the direct or indirect effects of the tumor or its treatment. Anaemia is an independent adverse prognostic factor that exerts negative influence on quality of life and survival of cancer patients. Anaemia in malignant disorders often arises from an interplay of multiple aetiological and pathophysiologic mechanisms. Understanding these mechanisms will help the oncologist identify and treat specific causes of the anaemia thereby minimizing the use of blood transfusion, which is associated with many adverse effects. This paper reviewed the various aetiological and pathophysiologic mechanisms of anaemia in cancer patients including direct and indirect tumour effects that lead to reduced red cell production or increased red cell destruction via a myriad of mechanisms ranging from marrow infiltration and cancer-associated acute myelonecrosis to chronic inflammation, blood loss, iron, folate, vitamin B12 and other nutrients deficiencies, malignancy related renal injury, pure red cell aplasia, hypersplenism, haemophagocytic syndrome, red cell autoantibody production, non-immune red cell fragmentation and cytotoxic therapy-induced erythroid cell apoptosis and eryptosis. Hence anaemia in cancer patients is attributable to a wide spectrum of aetiological factors with multiple and sometimes overlapping pathophysiologic mechanisms. It is therefore necessary for the oncologists to thoroughly investigate all cases of anaemia with the aim of identifying the actual causative factors in order to offer more sustainable cause-specific treatment modalities that will minimize the use of blood transfusion with its attendant adverse effects.|