Animesh Saha

Demographic and clinical profile of patients with brain metastases: A retrospective study.

Context: Brain metastases are the most common type of intracranial neoplasm, with the total number outnumbering primary brain tumors by a ratio of 10:1 and occur in about 25% of cancer patients. However, controversies exist regarding demographic and clinical profile of brain metastases. Aims: The purpose of this study was to analyze retrospectively the demographic and clinical profile of patients with brain metastases. Settings and Design: Retrospective, single institutional study. Materials and Methods: A retrospective study of 72 patients with brain metastasis was carried out from November 2010 to October 2012. The data pertaining to these patients was entered in a standardized case record form. These include History; clinical examination and other investigations including computed tomography/magnetic resonance imaging scan of the brain. Statistical Analysis: A statistical analysis was performed on the data collected using the MedCalc version 11. Results: Brain metastases were more common in male and occur in 6th decade of life mostly. There was no relationship of occupation or socio-economic status with the incidence of brain metastases. Carcinoma lung was the most common primary giving rise to brain metastases followed by breast. Adenocarcinoma accounts for most common histology of the primary that give rise to metastases. Multiple metastases were more common than the single group. Supratentorial lesions were more common than infratentorial lesions. Among them, parietal lobe was the most common site of involvement. Conclusions: The present study highlights that the incidence of brain metastasis is common in elderly population and mostly due to primary lung. Adenocarcinoma was the most common histology of primary. Majority of lesions has been observed at parietal lobe.

A randomized controlled pilot study to compare capecitabine-oxaliplatin with 5-FU-leucovorin as neoadjuvant concurrent chemoradiation in locally advanced adenocarcinoma of rectum.

CONTEXT Established as an adjuvant chemotherapy, CapeOX has recently been shown to have radiosensitizer property in a phase I and II studies, with appreciable downstaging and tolerable toxicities. AIMS The study was designed to evaluate whether the capecitabine-oxaliplatin combination was superior to 5-fluorouracil (5-FU)-leucovorin as radiosensitizer for neoadjuvant chemoradiation in downstaging locally advanced rectal adenocarcinoma and to compare the toxicities between the two arms. SETTINGS AND DESIGN Single institutional, double blinded, prospective, noncrossover, randomized control pilot study. SUBJECTS AND METHODS In arm A (n = 21), patients received capecitabine (1,000 mg/m(2) daily) in twice dailydoseon days 1-14 and 25-38 and oxaliplatin (85 mg/m(2)) intravenous ( IV) over 2 h, on D1 and D29. In arm B (n = 21), patients received leucovorin (20 mg/m(2)) and 5-FU (350 mg/m(2)) from D1-5 and D29-33. Patient in both the arms received concurrent radiation (50.4 Gy in 28 #, in conventional fractionation of 1.8 Gy per fraction). Six to eight weeks after concurrent chemoradiation, patients underwent assessment and surgery with total mesorectal resection. Postoperatively, adjuvant chemotherapy with m-FOLFOX 6 of 4 months was given to all patients. STATISTICAL ANALYSIS USED Chi-square test was used to compare categorical variables between the groups. RESULTS Objective response rate (ORR) in arm A was 80.95% compared to arm B which had 66.66% (P = 0.3055). Pathological complete response (pCR) rate of arm A was comparable to arm B (23.8 vs 14.28%, P value = 0.6944). Surgery with R0 resection was possible in 80.95% cases of arm A compared to 66.66% cases of arm B (P = 0.4827). Grade III toxicities were quite comparable between two treatment arms. CONCLUSIONS In terms of ORR, pCR rate, R0 resection, and toxicity profile; both the arms were comparable.

Correlation of clinicopathological outcomes with changes in IHC4 status after NACT in locally advanced breast cancers: do pre-NACT ER/PR status act as better prognosticators?

Background Following neoadjuvant chemotherapy (NACT) for breast cancer, changes in estrogen receptor (ER), progesterone receptor (PR), HER2 status, and Ki-67 index (IHC4 status) and its correlation with pathological complete response (pCR) or relapse-free survival (RFS) rates could lead to better understanding of tumor management. Patients and methods Pre- and post-NACT IHC4 status and its changes were analyzed in 156 patients with breast cancer. Associations between pCR, RFS rates to IHC4 status pre- and post-NACT were investigated. Results pCR was found in 25.3% patients. Both ER and PR positive tumors had the lowest (14.3%) pCR compared to ER and PR negative (29%) or either ER-/PR-positive (38.6%) tumors. PR positivity was significantly associated with less likelihood of pCR (15% versus 34%). The pCR rate was low for luminal A subtype (13.68%) compared to 24.36%, 26.31%, and 33.33% for luminal B, HER2-enriched, and triple-negative subtypes, respectively. There was significant reduction in ER expression and Ki-67 index post-NACT. RFS of patients in whom the hormonal status changed from positive to negative was better compared to those of patients in whom the hormonal status changed from negative to positive. Conclusion Although changes in IHC4 occurred post-NACT, pre-NACT hazard ratio status prognosticated RFS better. pCR and RFS rates were lower in PR-positive tumors.

Squamous cell carcinoma kidney in a 29-year-old male: A case report with review of literature

Primary malignant tumors of the renal pelvis are relatively rare with squamous cell carcinoma (SCC) accounting for 0.7-7%. Few cases of primary SCC of kidney have been reported in the world literature. The insidious onset of symptom and lack of any pathognomonic sign, leads to delay in the diagnosis and subsequent treatment, resulting in grave prognosis for these patients. We present a case of 29-year-old male with hydronephrosis of the left kidney with renal pelvis mass where histology of resected specimen shows SCC.

Helical tomotherapy based intensity modulated radiotherapy for the management of difficult clinical situations in breast cancer

Helical tomotherapy (HT) can achieve a homogenous dose distribution in the planning target volume while minimizing the dose to the organ at risk. Tomotherapy has been used for complex breast cancer radiotherapy including bilateral breast irradiation, pectus excavatum, and internal mammary chain (IMC) nodal irradiation. This report details our experience of using HT in breast cancers in newer clinical indications. Three patients with SCF nodal involvement (case 1), high level III axillary node recurrence (case 2), and composite irradiation of SCF, IMC, and whole breast (case 3) were treated using brachial plexus sparing HT. It was possible to boost the SCF, reirradiate the high level III axillary nodal recurrence and treat complex volume of breast, SCF, and IMC with acceptable and safe dose volume histogram constraints and with good homogeneity and conformity indices. The treatment was successful in controlling disease locoregionally at a 15 months follow-up. No patients reported symptoms suggestive of brachial plexopathy

Feasibility of organ preservation in muscle-invasive transitional cell carcinoma bladder: A single institutional approach

Background: Trimodality treatment initial transurethral resection of the bladder tumor [TURBT] followed by concurrent chemotherapy and radiation and organ preservation have been gradually replacing the radical cystectomy in muscle-invasive transitional cell carcinoma (TCC) of bladder. Aims: The aims of this study is to determine the clinical effectiveness, safety and protocol completion rate of trimodality treatment in muscle-invasive TCC of the bladder. Settings and Design: Prospective randomized and open-labeled study. Subjects and Methods: Patients with TCC of bladder, American Joint Committee on Cancer tumor node metastasis (TNM) Bladder Cancer Staging (2002) T2-3, N0, M0. Were underwent TURBT followed by three cycles of neoadjuvant chemotherapy with methotrexate, vinblastine, adriamycin, and cisplatin regimen. The patients were then randomized to receive either concurrent cisplatin 75 mg/m 2 in week 1 and 4 (arm-A) or no cisplatin (arm-B) along with external beam radiation therapy (EBRT) 45 Gy, in 25 fractions over 5 weeks. 4 weeks after completion of the initial phase of treatment, all patients were re-evaluated with TURBT. Those with complete remission (CR) received additional 15 Gy of EBRT in 8 fractions, while patients with residual disease were recommended for immediate radical cystectomy. All the patients of arm-B received boost dose of 15 Gy of EBRT. Statistical Analysis Used: The major statistical endpoints of this study were the CR rate at 8 weeks post-concurrent chemoradiotherapy (CCRT) and only radiotherapy. Statistical significance was accepted at the P < 0.05 (two-sided) level. Statistical analysis was performed entirely using the Statistical Package for the Social Sciences for Windows, version 17 (SPSS Inc., Chicago, IL, U.S.A.). Results: 8 weeks after completion of treatment 13/16 (81%) patients were in CR in CCRT arm (arm-A) compare to 6/15 (40%) patients receiving radiation only (arm-B). Conclusions: Patients, after TURBT receiving CCRT, had a better chance of organ preservation (81%) than those receiving radiation only.

Rhabdomyosarcoma thigh in a 45-year-old male: A rare presentation

Rhabdomyosarcoma (RMS) is a common childhood cancer, constituting more than 50% of all soft tissue sarcoma, but it is an uncommon neoplasm in adult. We reported a case of 45-year-old male patient presented with a huge swelling in his left thigh. Magnetic resonance imaging of thigh revealed soft tissue mass involving the deep muscular compartment. Core biopsy and immunohistochemistry confirmed it as an embryonal RMS. The tumor showed a complete response after three cycles of neoadjuvant chemotherapy (CT) and then was treated with three more cycle of CT followed by adjuvant radiotherapy. This case is being reported on account of its rarity at this age and nonsurgical treatment. Pertinent literature is being reviewed.

Treatment outcomes in patients with multiple brain metastases: A prospective randomized study

Context: There is controversy regarding the radiotherapeutic dose fractionation in brain metastases (bm). Aims: The aim of this study is to analyze the treatment outcomes in patients with multiple bm. Settings and Design: Prospective, randomized study. Subjects and Methods: Patients with multiple bm with Eastern Cooperative Oncology Group performance status ≤2 were included. In arm-A patient received whole brain radiotherapy (WBRT) 30 GY in 10# over 2 weeks and in arm-B patients received 20 GY in 5# over 1 week. Assessment of improvement in clinical symptoms was done using Barthels adjusted daily live (ADL) score. Assessment of radiological response was done using magnetic resonance imaging scan of brain after 3 months of completion of external beam radiation therapy. Acute radiation toxicity was assessed using Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer acute radiation morbidity scoring. Statistical Analysis Used: Chi-square test was used to compare categorical variables between groups. Overall survival was computed by Kaplan-Meier survival analysis and Log-Rank test used for comparison of survival plots. For change in quality-of-life during treatment and follow-up, repeated measures ANOVA were used. Results: In both arms, there was a significant improvement in ADL score after treatment, but when two arms were compared, no significant difference was found between the two treatment arms. There was no statistically significant difference in response or morbidity between the two treatment arms. Median survival was 29 weeks in arm-A compared to 25.86 weeks in patients arm-B. Kaplan-Meier Survival curve analysis shows no significant difference in survival between the two arms. Conclusions: 20 GY in 5 fractions is equally effective with that of the 30 GY in 10 fractions for WBRT in bm. In the palliative setting short duration of treatment with minimum discomfort to the patient is desirable. Hence, we can opt for 20 GY in 5 fractions in poor performance status patients and 30 GY in 10 fractions in patients with good performance status.

A randomized comparative study between neoadjuvant 5-fluorouracil and leukovorin versus 5-fluorouracil and cisplatin along with concurrent radiation in locally advanced carcinoma rectum

Context: Concurrent chemoradiotherapy (CCRT) with cisplatin-5-fluorouracil (CDDP-5FU) in rectal cancer is based on the concept of biochemical modulation. Aims: The study was designed to evaluate whether CCRT with CDDP and 5-FU is noninferior to CCRT with leukovorin (LV) and 5FU in downstaging locally advanced rectal adenocarcinoma and to compare the toxicities between the two arms. Settings and Design : Single institutional, noninferiority, prospective, randomized study. Subjects and Methods : In control arm ( N = 24) patients received chemotherapy. With bolus 5FU 350 mg/m 2 /day and LV 20 mg/m 2 /day for days 1-5 and 29-33. In study arm ( N = 25), patients received chemotherapy with bolus 5 FU 350 mg/m 2 /day for days 1-5 and 29-33 and CDDP 100 mg/m 2 /day at days 1 and 29. Patients in both the arm received concurrent radiation (50.4 Gy in 28#, in conventional fractionation of 1.8 Gy per fraction). Six to eight weeks after concurrent chemoradiation patients underwent assessment and surgery. Postoperatively, adjuvant chemotherapy with m-FOLFO × 6 of 4 months was given to all patients. Statistical Analysis : The Chi-square test was used to compare categorical variables between the groups. Results: Response rate as assessed by Response Evaluation Criteria in Solid Tumors (RECIST criteria) was comparable between the two treatment arms ( P = 0.9541). Pathological complete response rate of study arm was comparable to control arm (20 vs 20.83%, P = 0.7778 was not significant). Surgery with R0 resection was possible in 72% cases of study arm compared to 62.5% cases of control arm; P = 0.6861, not significant. Grade III toxicities were quite comparable between two treatment arms. Conclusions : In terms of pathologic complete response (pCR), R0 resection and toxicity profile of both the arms were comparable.