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January-March 2020
Volume 9 | Issue 1
Page Nos. 1-68

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ORIGINAL ARTICLE: BONE & SOFT TISSUE TUMORS  

Lymph node metastasis in extremity chondrosarcomas: A series of four cases p. 1
Vineet Kurisunkal, Ashish Gulia, Ajay Puri, Bharat Rekhi
DOI:10.4103/sajc.sajc_84_19  PMID:31956607
Background: Primary bone sarcomas mainly metastasize through haematogenous route and rarely through lymph nodes due to paucity of lymphatic channels in the bone (1). Nodal spread in chondrosarcoma is extremely rare and there are two reported cases in literature including one previously published by our institute (3, 5). Aims and Objectives: We present a series of chondrosarcoma cases (primary tumour located in the scapula, proximal femur, proximal humerus and pelvis), presenting with lymph node metastasis, treated at our institute. We assessed the oncological outcome of these cases and the impact of nodal metastasis on survival. Materials and Methods: Between January 2006 and December 2015, 243 patients of extremity and pelvic chondrosarcoma were operated at our institute. These cases were retrieved from a prospectively maintained database. Four (1.6%) of these patients developed lymph node metastasis. Clinical and radiological details of these cases were retrieved from electronic medical records and case files. Histopathology of the primary chondrosarcoma lesion and nodal metastasis was reconfirmed by a pathologist specializing in sarcomas. Conclusion: Lymph node metastasis though extremely rare in primary osseous chondrosarcoma, definitely affects their survival adversely. The rarity of the occurrence of lymph node metastasis in primary osseous tumors, especially chondrosarcoma highlights the need for multi institutional studies to pool knowledge and evaluate the prognostic significance and etiopathogenesis of lymph node metastasis in primary bone chondrosarcoma.
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ORIGINAL ARTICLE: BREAST CANCERS Top

Incidence of febrile neutropenia with commonly used chemotherapy regimen in localized breast cancer p. 4
Nageswara Reddy Palukuri, Rajani Priya Yedla, Stalin Chowdary Bala, Siva Prasad Kuruva, Rachana Chennamaneni, Meher Lakshmi Konatam, Sadashivudu Gundeti
DOI:10.4103/sajc.sajc_439_18  PMID:31956608
Introduction: Breast cancer is the most frequently diagnosed cancer among the women. Most commonly used chemotherapy regimen is Doxorubicin and Cyclophosphamide (AC) which carries significant risk of febrile neutropenia. The aim of the study is to identify the incidence of febrile neutropenia and its effects on the delivery of chemotherapy in patients receiving following AC chemoregimen without primary prophylaxis. Materials and Methods: We retrospectively analyzed the case records of the localized breast cancer patients who were treated with AC chemoregimen without primary prophylaxis for febrile neutropenia. Results: Between 2013 and 2017, a total of 231 cases received AC chemoregimen. A total of 14 (6.1%) patients were found to have febrile neutropenia. All patients were recovered by day 19 and no deaths were observed. Except for ECOG performance status (P = 0.001) no significant association was found with age, co-morbidities, menopausal status, body surface area and stage of the cancer. There were no treatment delays or dose reductions because of febrile neutropenia.Conclusion: The incidence of FN with AC chemotherapy in breast cancer patients is relatively less in the present study. Routine primary prophylaxis is not recommended as this chemotherapy falls in to low risk category for FN but can be considered for patients with ECOG PS > 1. If the diagnosis of febrile neutropenia and institution of appropriate measures are prompt, FN did not affect the delivery of chemotherapy and thus compromise survival.
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LETTERS TO THE EDITOR Top

An exceptional response to olaparib in relapsed and refractory BRCA2 mutated non-small cell lung cancer in hereditary breast–ovarian cancer syndrome p. 6
Vikas T Talreja, Vanita Noronha, Amit Joshi, Vijay Patil, Kumar Prabhash
DOI:10.4103/sajc.sajc_157_19  PMID:31956609
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ORIGINAL ARTICLES: EPIDEMIOLOGY OF CANCER AND CANCER SCREENING Top

Economics of cancer care: A community-based cross-sectional study in Kerala, India Highly accessed article p. 7
TA Dinesh, Prem Nair, V Abhijath, Vidya Jha, K Aarthy
DOI:10.4103/sajc.sajc_382_18  PMID:31956610
Background: The estimated incidence of cancer cases in Kerala for 2014 was 31,400 and the mortality associated with it was 13,816. Although the treatment of cancer has shown remarkable advances, it has come with increasing costs. Objective: The objective of this study is to estimate the economic burden of cancer in Vypin Block Panchayat at Ernakulam by analyzing the average total direct and indirect cost of cancer care, socioeconomic status, and cost of cancer care between government and private hospitals. Materials and Methods: A cross-sectional study was conducted for 2 months from March to April 2018. The study was conducted by utilizing an annotated cost questionnaire for completion by patients. Total direct and indirect cost was estimated. Appropriate statistical tests were used. Results: Direct cost for cancer care contributed 75% toward the cost of illness and the remaining was found to be indirect cost. Loss of income (44%) contributed to the largest chunk of indirect cost. The average direct cost for cancer care was found to be Rs. 25,606 and the average indirect cost was Rs. 8772. The average total cost of cancer care was calculated to be Rs. 34,378. Significant statistical variation was found between the cost of cancer care in private and government hospitals. The economic burden of cancer in this Vypin Block Panchayat was found to be Rs. 218,256,977/- Conclusion: The ratio of average income to average cost in this study is skewed which indicates the lack of affordability for cancer care in this population. A very large gap, therefore, exits between income levels and cost of cancer care clearly indicating a vast gap between affordability and cost of treatment, which clearly necessitates the need for a definite policy and state intervention for a mass cancer care program.
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ORIGINAL ARTICLE: EPIDEMIOLOGY OF CANCER AND CANCER SCREENING Top

Reliability of conventional Papanicolaou smear in diagnosing bacterial vaginosis among women with clinical genital infection Highly accessed article p. 13
Kavita Vivek Anand, Sharmila Anil Pimple, Gauravi A Mishra, Rupali V Sahare, Saleem Pathuthara, Kedar K Deodhar, Surendra S Shastri
DOI:10.4103/sajc.sajc_421_18  PMID:31956611
Objective: Bacterial vaginosis (BV) is a common reproductive tract infection (RTI) reported among Indian women. BV can influence the persistence of high-risk oncogenic human papillomavirus, a causative factor for cervical cancer. BV and cervical cancer are major public health issues in a developing country like India. It becomes important for a resource-constrained country like India with poor healthcare access to implement control measures to screen and treat RTI in an attempt to prevent the risk for cervical cancer. Papanicolaou (Pap) smear is an established screening tool for cervical cancer and the diagnosis of RTIs, forms a part of its evaluation. The present study explores the validity of conventional Pap smear in diagnosing BV. Methodology: Pap smear and Gram stain smear were collected for 254 women with clinically evident cervicitis/cervicovaginitis (genital infection). Using the Nugent score on Gram stain as a gold standard, we determined the sensitivity and specificity of Pap smear to diagnose BV. Results: The overall prevalence of BV in the study population was 44% using the Nugent score. Pap smear showed sensitivity and specificity of 70.9%. (CI- 61.5% - 79.2%) and 56.8% (CI – 48.2%–65.2%), respectively. The positive predictive value of Pap smear to diagnose BV was 56.5% (CI – 47.8%–64.9%), and the negative predictive value was 71.2% (CI – 61.8%–79.4%). Conclusion: In the present study, conventional Pap smear demonstrates good accuracy to detect BV. Pap testing for cervical cancer screening can additionally serve as an effective screening tool for diagnosing BV among women with genital infection in healthcare settings.
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ORIGINAL ARTICLES: EPIDEMIOLOGY OF CANCER AND CANCER SCREENING Top

Oral smokeless tobacco consumption pattern among rural Indian cancer patients: A prospective survey p. 17
Avinash Pandey, Anjana Singh, Shivkant Singh, Amit Kumar, Anshuman Das, Heena Shahi, Aishwarya Singh
DOI:10.4103/sajc.sajc_40_19  PMID:31956612
Background: Oral tobacco consumption predisposes to cancer. The pattern of its use in rural Indian cancer patients is unknown. Aim: The aim of this study is to estimate the prevalence of oral tobacco consumption in cancer patients. Objectives: To identify oral tobacco consumption pattern with respect to demographic variables and clinical profiles in adult Indian rural cancer patients. Materials and Methods: All consecutive individual adult (age >18 years) patients diagnosed with any cancer and registered in the Medical Oncology Outpatient department were enrolled for questionnaire-based survey on oral tobacco consumption between July 2017 and October 2017. Demographic variables were also recorded, including income, education, and occupation. Frequency distribution and cross-tabulation were used for statistical analysis using SPSS version 17. Results: Of 517 cancer patients enrolled, 456 (88%) were rural. 230/517 (44%) consumed several forms of oral tobacco. Out of 230, 179 (78%) of them had dried tobacco leaves, whereas 23 (10%) and 26 (11%) had Gutkha and pan (betel leaves) alone, respectively. 63 (27%) consumed tobacco leaves and gutkha both. 163 (91%) of tobacco chewers were male, whereas 65% of pan chewers were male and 35% of females. About 48% of tobacco chewers were addicted since >20 years, whereas 13% started in the past 5 years. 47/179 (26%) of tobacco chewers were illiterate, whereas 13/179 (7.2%) were graduates. 106 (59%) had monthly income of between Rs. 5000–10,000. 57 (32%) and 40 (22%) were farmers and laborers, respectively. 25/215 (12%) housewives were addicted. 41/58 (70%) of the head-and-neck cancer patients consumed tobacco products, where 29/41 (70%) used dried tobacco leaves to chew. Conclusion: More than 40% of adult Indian rural cancer patients consume oral smokeless tobacco products. Dried tobacco leaves are the most common form of smokeless tobacco consumed.
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ORIGINAL ARTICLES: GI CANCERS Top

A prospective comparative study between concurrent chemoradiation with brachytherapy boost with concurrent chemoradiation alone in locally advanced cancer esophagus p. 20
Rajanigandha Tudu
DOI:10.4103/sajc.sajc_63_19  PMID:31956613
Context: Carcinoma esophagus is a highly malignant disease with very low cure rate. Concurrent chemoradiation is the standard of care in patients deemed unfit for surgery. Intraluminal brachytherapy (ILRT) is effective for palliation of dysphagia and is also used as a boost to external beam radiotherapy (EBRT) in curative intent. Aims: The aim of the study was to compare the clinical outcome of definitive concurrent chemoradiation followed by ILRT boost with concurrent chemoradiation alone in locally advanced carcinoma esophagus in terms of tumor response and toxicities. Settings and Design: A single institutional prospective study was carried out between January 2014 and June 2015. Subjects and Methods: Fifty-seven patients of locally advanced carcinoma esophagus were allocated to study and control arms. Both groups were treated with definitive concurrent chemoradiation with 44 Gy of EBRT. The chemotherapy consisted of injection cisplatin 70 mg/m2 intravenous on day 1 with capecitabine 800 mg/m2 b.i.d. daily from day 1 to 4 orally on days 1 and 22 of EBRT. After 2 weeks, the control group was treated with EBRT boost of 10 Gy in 5 fractions, while the study group received intraluminal high-dose rate (HDR) brachytherapy boost of 10 Gy in 2 fractions. No concurrent chemotherapy was administered during ILRT. The treatment outcome was assessed in terms of tumor response and toxicities using the CTCAE version 4.0 criteria. Results: At a median follow-up of 10 months, the overall response rate was 89.2% in the control group (25/28) and 93.10% in the study group (27/29). Acute hematological and gastrointestinal toxicities were noted.Conclusions: HDR ILRT in combination with EBRT is effective for treating dysphagia in cancer esophagus with low incidence of severe complications.
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LETTERS TO THE EDITOR Top

A rare case of hyperprogression of nonsmall cell lung cancer in a patient on atezolizumab therapy p. 22
Sudarsan Vishnu Kollimuttathuillam, Supreet Kaur, Hamid Shaaban, Gunwant Guron
DOI:10.4103/sajc.sajc_166_19  PMID:31956614
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ORIGINAL ARTICLES: GENITOURINARY CANCERS Top

A tertiary care audit of using abiraterone acetate in patients of metastatic castrate-resistant prostate cancer p. 23
Amit Joshi, Sameer Shrirangwar, Vanita Noronha, Nilesh Sable, Archi Agarwal, Palak Popat, Atanu Bhattacharjee, Kumar Prabhash
DOI:10.4103/sajc.sajc_433_18  PMID:31956615
Introduction: This is a retrospective analysis to assess the safety and efficacy of abiraterone acetate (AA) in metastatic castrate-resistant prostate cancer (mCRPC) patients treated at tertiary care institute. Materials and Methods: The clinical records of mCRPC patients treated with AA at our tertiary care institute between July 2013 and December 2015 were reviewed. The treatment efficacy, toxicities, and its determinants were analyzed. Results: A total of 59 mCRPC patients treated with AA were reviewed, of whom 37 were chemo-naive and 22 had received prior chemotherapy (postchemo). The median follow-up duration was 10.0/15.0 months for chemo-naïve/postchemotherapy patients. 43.2%/36.36% of chemo-naive/postchemo patients had visceral metastases. The median overall survival (OS) and progression-free survival (PFS) were 15/7.8 months and 10/5.3 months for chemo-naive/postchemo patients, respectively. Median time to best prostate-specific antigen response was 3.4 months. Abiraterone was relatively well tolerated with no grade 4 toxicity or treatment-related death. We found the presence of previous taxene use and baseline symptoms to be significantly determinant of OS with abiraterone. Conclusion: The present study reported the efficacy of abiraterone in both chemo-naïve and postchemo patients of mCRPC outside clinical trial setting. We found lower OS and PFS with abiraterone as compared to that reported in the clinical trial setting in both chemo-naïve and postchemo patients, and particularly in those patients with the visceral disease, and further clinical trial for abiraterone in this subgroup of patients is warranted.
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Primary malignant mediastinal germ cell tumors: A single institutional experience p. 27
Subhasis Mishra, Saroj Kumar Das Majumdar, Mukund Sable, Dillip Kumar Parida
DOI:10.4103/sajc.sajc_47_19  PMID:31956616
Background: Primary mediastinal malignant germ cell tumour (PMMGCT) is rare with unsatisfactory prognosis and pose difficulty in management due to lack of guidelines. Methods: All cases of PMMGCT diagnosed and treated between years 2014 to 2018 were retrospectively evaluated for clinico-pathological features, multimodality treatment and follow up. Results: Among a total of five PMMGCT cases, three were seminomatous and two were non seminomatous tumour [Yolk- sac tumour (n-1) and Mixed tumour (n-1)]. Four of these cases were non - metastatic with locally advancement and another one presented with metastasis to supraclavicular lymph node. All patients received platinum based induction chemotherapy. Post-induction chemotherapy, two cases of non seminomatous tumours underwent surgery. Among the three seminoma cases, one patient showed complete metabolic response; one with metastasis succumbed to the disease and the in-operable case of seminoma received local radiotherapy. Conclusion: PMMGCT needs a multi-disciplinary approach for appropriate diagnosis and management. Clinicopathological features like tumour site, extension, histopathological type, tumour stage and serum tumour marker are necessary for prognostication and decision making of further treatment plan.
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ORIGINAL ARTICLES: GYNAECOLOGIC CANCERS Top

Does preoperative CA-125 cutoff value and percent reduction in CA-125 levels correlate with surgical and survival outcome after neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer? – Our experience from a tertiary cancer institute p. 30
Monisha Gupta, Shilpa Mukesh Patel, Ruchi Arora, Rajneesh Tiwari, Pariseema Dave, Ava Desai, Meeta Mankad
DOI:10.4103/sajc.sajc_53_17  PMID:31956617
Aim: The aim of the study is to evaluate percent fall in CA-125 levels after neoadjuvant chemotherapy (NAC) and preoperative CA-125 value to predict surgical and survival outcomes in women with advanced-stage epithelial ovarian cancer (EOC). Methods: A retrospective review of 406 women receiving NAC for advanced-stage EOC from January 2012 to July 2015 was conducted. Data were collected for demography, radiographic profile, CA-125 levels before and after NAC, chemotherapy, and surgicopathological information. Percent fall in CA-125 was categorized into two groups: <95% (R < 95) and >95% (R > 95) fall from prechemotherapy to preoperative levels. Similarly, women were also categorized using preoperative CA-125 levels of <100 and >100 U/ml. A subset of women from January 2012 to December 2013 was followed to June 2015 for evidence of any recurrence to determine survival outcomes. Results: About 56% women had R > 95 and 44% had R < 95. As compared to R < 95, R > 95 group was more likely to have complete cytoreduction (P = 0.00). Furthermore, women with R > 95 had significant better progression-free survival (PFS) as compared to women with R < 95 (P = 0.009) but no difference in overall survival (OS) (P = 0.28). Women with preoperative CA-125 <100 had significant higher number of complete cytoreduction (55% vs. 40%; P = 0.00) and were associated with both PFS (P = 0.007) and OS benefit (P = 0.02). Conclusion: Our data showed that >95% fall in CA-125 and an absolute preoperative CA-125 value of <100 U/ml is associated with better surgical and survival outcome in women with advanced EOC. These data are important in patient counseling and treatment planning.
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ORIGINAL ARTICLES: HEAD AND NECK CANCER Top

Adequacy of surgical margins in oral cancer patients with respect to various types of reconstruction p. 34
Apurva Garg, Manish Mair, Hitesh Singhavi, Muddasir Bhati, Akshat Malik, Aseem Mishra, Deepa Nair, Sudhir Nair, Pankaj Chaturvedi
DOI:10.4103/sajc.sajc_366_18  PMID:31956618
Background: Surgical margin is an important prognostic factor for oral cancers (oral squamous cell carcinoma [OSCC]). The correlation of margin with the type of reconstruction has never been studied. Aim: This study aimed to correlate surgical margins with the type of reconstruction. Methods: This was a retrospective study of 410 treatment-naïve OSCC patients. As per the methods of reconstruction, three groups were made when reconstruction was performed using pedicled flap (PF) or local flap, free flap, and primary closure (PC). Statistical Analysis: Chi-square test was used for comparison of margin status as per the method of reconstruction. Mann–Whitney test was used to find the difference between the mean margin width with respect to the type of reconstruction. Results: The overall incidence of close/positive margins was 7.8%. The incidence of close/positive margins was not significantly different in free flap group compared to PF (P = 0.06) or PC (P = 0.835) group. However, there was a significant difference in the incidence of close/positive margins between PC and PF groups (P = 0.021). Whether the reconstruction is performed by the primary surgeon or by a another surgeon, it did not have an impact on adequacy of margins (P = 0.334). Margins were wider when the reconstruction is performed by a different team (P = 0.015) or when reconstruction is performed as compared to PC. Conclusion: Margins are not affected by the type of reconstruction (pedicled vs. free flap) and the team doing reconstruction (same vs. another team). Margins are significantly compromised when a surgeon performs PC himself/herself compared to PF.
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LETTERS TO THE EDITOR Top

Myeloma-associated amyloid arthropathy masquerading as seronegative arthritis p. 37
Akanksha Garg, Pradeep Kumar, Ram Nawal Rao, Rajesh Kashyap
DOI:10.4103/sajc.sajc_235_19  PMID:31956619
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ORIGINAL ARTICLES: HEAD AND NECK CANCER Top

Demography and treatment pattern of patients with head and neck carcinoma presenting to a tertiary care center in India: Need for urgent decentralization of cancer care p. 38
Mihir N Chandarana, Prathamesh S Pai
DOI:10.4103/sajc.sajc_26_19  PMID:31956620
Aims: This study aims to report on the demographic profile and treatment pattern of head and neck cancer patients and impact of an early treatment decision on treatment. This study also aims to suggest recommendations to improve treatment compliance. Methods: All new patients registered under the head and neck disease management group (DMG) over a period of 3 months at a single center were included. Their demographic details, time to treatment decision, and treatment compliance were determined. The findings were presented to head and neck DMG, and changes were implemented to patient workup with an aim to improve compliance. A reaudit was performed over a period of 3 months and results were compared. Results: Two thousand two hundred and forty patients were included in the analysis. Patients with a treatment decision at 1–4 weeks stood at 28.32%, 63.88%, 80.8%, and 89.87%, respectively. Dropout rate was 26%. About 50% of patients planned for surgical intervention could be treated within the institution. After implementation of changes as recommended by DMG, 2418 patients were analyzed and findings were compared to the previous audit. The dropout rate reduced to 17.57%. The number of patients with a treatment decision at 1–4 weeks were 51.26%, 77.42%, 89.46%, and 94.31%, respectively. Conclusion: Early treatment decision and referral could significantly improve patient dropout and possibly compliance to treatment. Decentralization of cancer care is urgently needed to manage the high numbers of patients presenting to tertiary care centers. Setting up of new regional cancer centers and increasing infrastructure in the existing centers should be the long-term goals.
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Nimotuzumab with intensity-modulated radiation therapy in unresectable and platinum-ineligible locally advanced head-and-neck cancer p. 43
K Satish Srinivas, Raja Sundaram, CV Divyambika, Sameer Chaudhari
DOI:10.4103/sajc.sajc_29_19  PMID:31956621
Background: Outcomes with conventional treatment are poor in patients with squamous cell carcinoma of head and neck (SCCHN). Treatment options are further limited for patients ineligible to receive platinum-based chemotherapy due to various factors such as geriatric age, comorbidity, and organ dysfunctions. The present study retrospectively evaluated the effectiveness of nimotuzumab when added to radiation therapy in unresectable, locally advanced SCCHN patients who were ineligible for platinum-based chemotherapy. Materials and Methods: The medical records of 21 patients with unresectable, locally advanced head-and-neck cancer and histologically confirmed squamous cell carcinoma who were ineligible for platinum-based chemotherapy treated with nimotuzumab and intensity-modulated radiation therapy (IMRT) from 2012 to 2017 were retrospectively analyzed. The tumor response rate and overall survival (OS) were analyzed. Patients were assessed for toxicity and adverse events (AEs) as per CTCAE version 4. Statistical analysis was performed using SPSS software. Results: The median number of doses of nimotuzumab received was 6, and median dose of radiotherapy was 60 Gy. The tumor response rate was calculated at 24 weeks after the completion of radiotherapy and was as follows: 76.2% (16) of patients showed complete response, 9.5% (2) of patients showed partial response, 4.8% (1) of patients showed stable disease, and 9.5% (2) of patients showed progression of disease. Median OS was 21 months, whereas 1-year survival rate was 63.7%. No Grade 3 or Grade 4 AEs were observed. Conclusion: Nimotuzumab with IMRT has achieved promising clinical outcomes in unresectable locally advanced SCCHN patients who are ineligible for platinum-based chemotherapy, without accumulation of toxicity.
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ORIGINAL ARTICLES: LUNG CANCERS Top

Third-line therapy in the epidermal growth factor receptor mutation-positive advanced nonsmall-cell lung cancer p. 47
Vanita Noronha, Nikhil Pande, Amit Joshi, Vijay Patil, Vaishakhi Trivedi, Anuradha Chougule, Amit Janu, Abhishek Mahajan, Vikas Talreja, Kumar Prabhash
DOI:10.4103/sajc.sajc_28_19  PMID:31956622
Introduction: The treatment of lung cancer is not defined in the third-line setting and remains an unanswered question. Erlotinib is the only drug approved in the third-line setting. With the introduction of effective first- and second-line therapies, more and more patients warrant an effective third-line therapy. We did a post hoc analysis of our randomized trial for the epidermal growth factor receptor (EGFR)-positive patients who received third-line therapy. Materials and Methods: The present series is of 85 patients who received third-line therapy. Demographic data were collected which included age, performance status, gender, stage, comorbidities, and sites of metastasis. Data were collected for the type of systemic treatment patients received and number of cycles received. Information related to the impact of treatment on the symptoms of patients and the imaging done for response evaluation was collected. Results: Of the 85 patients, there were 13 patients (15%) who achieved a partial response and 34 patients (40%) who had stable disease as best response. There were no complete response and 20 patients (24%) had disease progression at the time of first assessment. The median overall survival (OS) was 8.36 months (95% confidence interval [CI] 6.8–9.8 months) and median progression-free survival was 4.4 months (95% CI 3.3–4.9 months). Grade 3 or 4 toxicities were seen in 42.5% (n = 36) of the total patients. Conclusions: The study provides the patterns and outcomes of systemic treatment in metastatic EGFR-mutated lung adenocarcinoma in patients who have progressed on two or more lines of systemic therapies. This data suggest that third-line systemic therapy may provide meaningful outcomes in these patients.
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The real-world experience with nivolumab in previously treated patients with advanced non-small cell lung cancer from a cancer center in India p. 50
Waseem Abbas, Rudra Prasad Acharya, Archit Pandit, Saurabh Gupta, Ranga Raju Rao
DOI:10.4103/sajc.sajc_111_19  PMID:31956623
Background: PDL-1 inhibitors have emerged as the new standard of care for second line treatment of NSCLC. Methods: Eligible patients included, histologically proven NSCLC, ECOG (Eastern Cooperative Oncology Group) performance status of 0, 1 or 2, age 18 years and above, availability of pre-treatment tumor specimen, adequate end organ function, at least one prior platinum-based therapy. Patients who received a minimum of 6 doses of nivolumab were eligible. Results: Eleven previously treated patients with chemotherapy, started on nivolumab from April of 2016 to December of 2018, were retrospectively studied and analysed. The median age of patients was 58 years. Eight (72.73%) of the eleven patients were male. Seven (63.64%) of the patients were current or former smokers. Majority of patients had non-squamous histology; seven (63.64%) adenocarcinoma and four (36.36%) squamous cell carcinoma. 5 (45.46%) of the patients received one prior therapy, three (27.27%) received two prior therapies, and three (27.27%) received three prior therapies. Four (36.36%) of the patients had brain metastasis. Two (18.18%) of the patients were more than 70 years of age. Median number of cycles of nivolumab administered were 10 (range, 6 to 21). At the time of analysis, the median PFS was 8 months (95% CI, 1.52-14.47) and median OS was 15 months (95% CI, 6.9-23.09). Treatment was well tolerated and generally side effects were grade 1 and grade 2, except two patients who develop grade 3/4 pneumonitis. Conclusions: This is a real-world study of eleven previously treated patients with chemotherapy, started on Nivolumab from April of 2016 to December of 2018. Although, our sample size was small, our data supports the use of nivolumab as a new treatment option for patients of stage 4 NSCLC.
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ORIGINAL ARTICLES: PEDIATRIC AND ADOLESCENT CANCERS Top

Pediatric cancers in Bihar: A retrospective tertiary cancer center study p. 53
Avinash Pandey, Anjana Singh, Vijendra Kumar, Jayant Prakash, Ritesh Runu, Vinit Thakur, Anand Kumar Gupta, Shivkant Singh
DOI:10.4103/sajc.sajc_48_19  PMID:31956624
Background: There is lack of information regarding pattern of distribution of pediatric cancers in Bihar. Aim: The aim of this study is to identify the pattern of distribution of pediatric cancers. Objectives: To analyze demographic data, type, and pattern of pediatric cancers in Bihar by retrospective clinical audit. Materials and Methods: All individual consecutive patients between ages 0 and 18 years registered in the Department of Medical and Pediatric Oncology from January 1, 2018 till December 31, 2018, were enrolled in this study. Data pertaining to age, sex, and type of cancer were retrieved from clinical database by retrospective audit and stratified into hematolymphoid and solid pediatric cancer cohorts. Frequency distribution and descriptive statistics were used to analyze the data using SPSS version 17.0. Results: A total of 247 pediatric cancers were registered, of which 142/247 (57%) and 15/247 (43%) were pediatric hematolymphoid and solid cancers, respectively. The median age was 9 years, while male-to-female ratio was 2.26. Acute lymphoblastic leukemia (ALL), 76/247 (31%) was the most common pediatric cancer overall. Hodgkin's lymphoma, 27/142 (19%) was the second most common hematolymphoid malignancy, after ALL was 76/142 (54%). Among solid tumors, Wilms' tumor was the most common, 28/105 (27%) followed by Ewing's sarcoma, 16/105 (15%), and germ cell tumor, 15/105 (14%). Central nervous system malignancies were among the least common solid tumor cancers, 3/105 (3%). Conclusion: ALL and Hodgkin's lymphoma are the most common pediatric cancers. Among solid malignancies, Wilms tumor, Ewing's sarcoma, and Germ cell tumor are predominant.
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Epidemiology and clinical features of retinoblastoma: A tertiary care center's experience in India p. 56
Maneya Padma, Nuthan Kumar, Prerana S Nesargi, BS Aruna Kumari, L Appaji, Aarthi Viswanathan
DOI:10.4103/sajc.sajc_89_19  PMID:31956625
Introduction: Retinoblastoma (RB) is a prototype of heritable cancers. It is more common in the lower socioeconomic strata. Delayed presentation significantly reduces the overall outcome. We have analyzed the epidemiological and clinical data of children who were diagnosed with RB between the years 2009 and 2014. Aim: RB being a disease of the poor, delayed presentation is common due to lack of awareness. We have analyzed the epidemiological profile of our patients and tried to establish the link between delayed presentation and the presence of high-risk features. High-risk features are associated with higher chance of metastasis and poor rates of vision salvage in RB. Methodology: Data were collected in a retrospective manner from the patient case files retrieved from the Medical Records Department, Kidwai cancer Institute. The data were analyzed using Excel and SPSS software (IBM Corp. released 2016, IBM SPSS statistics software for Mac OS, version 24, IBM Corp., Armonk, NY). Results: A total of 53 patients were diagnosed with RB in the years 2009–2014. There was a male predominance with 1.2:1 incidence. Bilateral RB was present in 21 cases. The mean age of children with bilateral RB was 2.1 years, against 1.5 years in unilateral cases. High-risk features such as optic nerve invasion, choroidal invasion, intracranial extension, and orbital involvement were found in 12, 6, 5, and 5 eyes, respectively. Bone marrow involvement was detected in 5% and lung metastasis in 2%. Intracranial involvement was found in 10.4% and cerebrospinal fluid positivity in 15%. Children with high-risk features had a significant delay in presentation in comparison to those without high-risk features (P = 0.035). Conclusion: Incidence of metastatic disease and delayed presentation is still high in developing countries. Routine eye examination during vaccination visits can ensure early diagnosis and appropriate referral in many of these children.
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LETTERS TO THE EDITOR Top

Isolated regional nodal metastasis in giant cell tumor of the bone: Case report and review of literature p. 58
Kanuj Malik, Anand Raja, Sundersingh Shirley
DOI:10.4103/sajc.sajc_244_19  PMID:31956626
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ORIGINAL ARTICLES: SUPPORTIVE CARE AND OTHERS Top

Role of Cresp® in the management of chemotherapy-induced anemia in cancer patients: A real-world clinical practice audit p. 59
Ghanshyam Biswas, Avinash Pandey, Nikhil Ghadyalpatil, Nilesh Lokeshwar, Boben Thomas, Anita Ramesh, Yogesh Arora, Chandragouda Dodagoudar, Vibha Naik, Ashish Joshi, Indranil Ghosh, Rakesh Roy, Medhi Kunjahari, Tejinder Singh, Palanki Dattatreya Satya, Sachin Hingmire, Purvish M Parikh
DOI:10.4103/sajc.sajc_246_19  PMID:31956627
Introduction: Anemia is a common, underestimated problem in cancer patients receiving myelosuppressive chemotherapy and has significant adverse effect on the quality of life and outcome. Darbepoetin has been shown to be effective in this setting, but controversy surrounds it actual use. Methods: We analyzed prospectively collected clinical practice data of patients receiving darbepoetin in a real-world setting for this retrospective audit. Patients with baseline hemoglobin (Hb) of <11 g/dl were included in this analysis. Their medical records were audited using a predetermined 35-point pro forma. Results: There were a total of 274 patients with advanced cancer receiving myelosuppressive chemotherapy who had baseline Hb <11 g/dl and who were given darbepoetin. Head-and-neck squamous cell carcinoma, lung cancer, and breast cancer were the most common cancers. Their median baseline Hb was 8.9 g/dl which rose to 11.2 g/dl at the end of commenced therapy, along with improved symptomatology. There were no new toxicities, and only two patients required discontinuation of darbepoetin due to toxicity. Conclusion: Darbepoetin is safe and effective in the prevention and management of anemia among patients receiving myelosuppressive chemotherapy.
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How cancer of oral cavity affects the family caregivers? – A cross-sectional study in Wardha, India, using the Caregiver Quality of Life Index – Cancer questionnaire p. 62
Sourav Goswami, Subodh Saran Gupta
DOI:10.4103/sajc.sajc_331_18  PMID:31956628
Introduction: Oral cancer is now a major public health problem in India. It does not only affect the patient, but also has a deep psychosocial impact on the family caregivers who are deeply involved with the cancer patient for nursing, timely medication, and consulting the doctor. Studies have found that the caregivers often suffer from depression, anxiety, and fear of losing their near and dear ones. This study aims to capture the psychosocial impact of oral cancer on the family caregivers. Materials and Methods: This was a cross-sectional study carried out in a tertiary care hospital with the primary caregivers of those oral cancer patients who completed their treatment and came for follow-up after 2–3 months of treatment completion. The study participants were recruited till a sample size of 100 was reached. This was adequate to report proportions with an error of 10%. We have used “The Caregiver Quality of Life Index – Cancer” scale to capture the psychosocial impact of oral cancer on primary caregiver of the patient. The study was initiated after obtaining approval from the Institutional Ethics Committee. Informed written consents were obtained from all the study participants before beginning the interviews. Results: Caregivers played an important role in the recovery of the patients. However, the strain of caregiving resulted in increased emotional stress among them. We found 56% of the family caregivers were female and 41% were male. Majority of the caregivers who accompanied the patients to hospital were the spouses. For the caregivers, the mean score for burden of the disease was found to be 60.0 (±20.2), that for disruption was 50.4 (±21.7), and for positive adaptation was 61.4 (±20.7). Conclusion: Caregivers, who are usually invisible to the health-care team, should be recognized and their mental and physical well-being should also be given attention.
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LETTERS TO THE EDITOR Top

Lorlatinib in anaplastic lymphoma kinase-positive non-small cell lung cancer: Indian experience p. 67
Vikas T Talreja, Vanita Noronha, Vijay M Patil, Amit Joshi, Kumar Prabhash
DOI:10.4103/sajc.sajc_364_19  PMID:31956629
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