Jyoti Bajpai

Acute non-ST elevation myocardial infarction following paclitaxel administration for ovarian carcinoma: A case report and review of literature

We report a case of an acute non-ST elevation myocardial infarction (AMI) induced by paclitaxel in a patient with ovarian cancer. A 45-year-old premenopausal lady without any co-morbidity was started on the first cycle of neoadjuvant chemotherapy with paclitaxel-based regimen for advanced stage ovarian cancer. The patient developed chest pain 3 h after paclitaxel infusion with characteristic electrocardiographic changes of antero-apical myocardial infarction. The patient recovered on conservative medical management with reversion of electrocardiogram (ECG) changes. Cardiac ischemia and myocardial infarction, possibly due to coronary vasospasm, are rare adverse effects of paclitaxel with reported incidence of 0.26%. We have reported a case of paclitaxel-induced myocardial infarction with reversible cardiac dysfunction. The possibility of myocardial infarction should be considered in patients who develop chest pain or other symptoms after paclitaxel infusion.

Outcome of Gestational Trophoblastic Neoplasia: Experience from a Tertiary Cancer Centre in India

AIMS Gestational trophoblastic neoplasms (GTN) comprise a spectrum of interrelated conditions originating from the placenta. With sensitive assays for human chorionic gonadotropin (β-hCG) and current approaches to chemotherapy, most women with GTN can be cured with preservation of reproductive potential. The purpose of this analysis was to address the outcome of GTN from a developing country, as data are largely sparse from this region. MATERIALS AND METHODS We undertook a retrospective review of GTN cases treated at our centre from 2001 to 2008. Patients of GTN were assigned to low-risk (score ≤ 6) or high-risk (score ≥ 7) categories as per the modified World Health Organization scoring system. The low-risk group was treated with single-agent methotrexate (MTX) and the high-risk group received the EMA/CO regimen. Salvage therapies were EMA/EP or BEP. Treatment was continued until serum β-hCG values were normal for three consecutive chemotherapy cycles, after which the patients were kept on follow-up. RESULTS In total, 70 GTN patients were treated at our institution during this period; 48 (68%) were low-risk and 22 (32%) were in the high-risk category. The median β-hCG level was 50 000 IU/l. The lung was the most common site of metastasis, seen in 15 (21%) patients. Among 48 low-risk patients, 37 (77%) received chemotherapy, of whom 25 (68%) were treated with MTX and 24 (96%) achieved a complete response. Twelve low-risk patients (32%) received EMA/CO therapy; 10 (83%) achieved a complete response. The 22 high-risk patients received EMA/CO and of these 16 (73%) achieved a complete response, two (9%) progressed, two (9%) died of progressive disease and two (9%) were lost to follow-up. Grade 3/4 toxicities with MTX included mucositis in two (8%) and neutropenia in five (21%) patients. At a median follow-up of 16.6 months, overall survival in the low- and high-risk groups was 100 and 88.8%, respectively. CONCLUSION Risk-stratified treatment of GTN was associated with acceptable toxicity and resulted in outcome that was comparable with international standards.

Impact of adjuvant radiation therapy photon energy on quality of life after breast conservation therapy: Linear accelerator versus the cobalt machine

BACKGROUND Breast conservative therapy (BCT) is a standard treatment option in early operable breast cancers (OBC) and a select group of large or locally advanced tumors. The present study deals with prospective evaluation of quality of life (QOL) score in consecutive patients treated with BCT employing adjuvant RT treated with either a cobalt machine or a linear accelerator (LA). MATERIAL AND METHODS Patients of carcinoma breast who underwent BCT were taken into the study. Patients with larger breasts (inter-field separation >18-20 cm) were treated on LA and those with smaller breasts were treated on cobalt machine. All patients received a uniform RT dose (45-50 Gy/25#/5 weeks) to whole breast followed by tumor bed boost with suitable energy electrons. Prospective evaluation of QOL was done using EORTC QLQ C30 and breast cancer-specific EORTC QLQ BR23. QOL evaluation was done at pre-RT, at half completion of RT treatment (at 20-23 fractions) and at completion of RT. RESULTS Pre-RT evaluation GQOL scores in patients treated with cobalt and LA were 71.6 and 71.7, respectively (P = 0.8). QLQ C30 functional and symptom domain scores were also similar in the groups. At RT completion, Global quality of life (GQOL) scores were 67.7 in patients treated with cobalt as compared to 77.7 in patients treated with LA (P = 0.75). Physical function domain scores in cobalt and LA patients were 70.8 and 80.3, respectively (P = 0.26). Fatigue score was higher in patients treated with cobalt (39.1 versus 29.7; P = 0.9). However, there was no difference in other functional and symptom domains. There was no significant change in any of the EORTC QLQ C30 domains at RT completion as compared to the pre-RT scores. CONCLUSION There is no significant difference in QOL domains between appropriately selected patients treated with cobalt and LA. There are no significant changes in QOL domain scores at RT conclusion as compared to pre-RT baseline in patients treated with cobalt or LA source. A cobalt machine may be effectively used to deliver adjuvant RT in appropriately selected BCT patients especially in developing countries with limited resources.

Management of Isolated Locoregional Recurrences in Breast Cancer: A Review of Local and Systemic Modalities

Abstract Locoregional recurrence (LRR) after adequate treatment of primary breast cancer poses a therapeutic challenge. Advances in the management of breast cancer have led to significant improvements in survival. With this advantage, it is observed that the incidence of LRR has relatively decreased. Systemic involvement should be ruled out in patients presenting with locoregionally recurrent disease, as isolated LRR requires a treatment with curative intent. Salvage mastectomy following ipsilateral breast tumor recurrence is a time‐tested treatment option and widely accepted. Second‐time breast conservation surgery with or without radiotherapy is an emerging alternative. Following a second breast conservation, partial breast irradiation has been seen to improve local control. Five‐year overall survival with second breast conservation and radiotherapy is in the range of 76% to 100% with acceptable toxicities. Isolated chest wall recurrences after mastectomy are difficult to manage. Multimodality treatment has been adopted to treat chest wall recurrences, following which the 5‐year overall survival was observed to be in the range of 45% to 60%. Use of hyperthermia and photodynamic therapy in combination with conventional treatment options has been associated with better clinical outcomes. Systemic therapy, in the form of chemotherapy and/or hormonal therapy in addition to adequate locoregional treatment, has shown to improve survival. Multimodality treatment for isolated regional recurrences has been associated with better outcomes, and the 5‐year survival rates are around 50%. All patients with LRR should be evaluated by a multi‐disciplinary tumor board to individualize treatment based on the expected risk‐benefit ratio of retreatment.

Clinicopathological spectrum of 19 adenosarcomas of female genital tract, including uncommon clinical associations and immunohistochemical profile, reviewed at a single institution.

BACKGROUND Adenosarcomas of the female genital tract have been rarely documented as case series from our continent. MATERIALS AND METHODS Over a seven-year period, 19 adenosarcomas were critically reviewed. RESULTS Nineteen tumors occurred in the age range of 21-65 years (mean: 43), in the endometrium (8), endometrium and cervix (4), cervix (4), and ovary (3). Four cases displayed coexisting leiomyomas; two, adenomyosis; two on background endometriosis; and one in post-treated cervix carcinoma. Histopathologically, the tumors were low grade (10; 52.6%) and high grade (9; 47.3%), the latter with sarcomatous overgrowth (SO) (7/9 cases). Dedifferentiation (8, 42.1%) and conspicuous decidualization (2) were noted. Immunohistochemically, the tumors focally expressed CD10 (4/6), smooth muscle actin (SMA) (3/8), desmin (8/11); diffuse vimentin (7/7), and estrogen receptor/progesterone receptor (ER/PR) (2/4). Ki-67 (6 cases) varied 5-20%. Seventeen patients underwent surgery and four received adjuvant treatment (3/4 high-grade tumors). Five tumors recurred (4 high-grade tumors with SO) and one metastasized. Among 11 patients, five were alive with disease (AWD) (mean: 29.4 months) and six, free of disease (FOD) (mean: 15 months), the latter mostly with low-grade type tumors (83.3% cases). CONCLUSIONS Diverse clinicopathological spectrum was noted within adenosarcomas. Low-grade tumors were less aggressive than high-grade ones, with SO. Immunohistochemically, lower CD10 and ER/PR positivity was noted in high-grade tumors. Surgery formed the mainstay of treatment. Adjuvant treatment was offered in high-grade subtypes, including in tumors with SO.

Breast cancer: An overview of published Indian data

The Incidence of breast cancer has been steadily increasing in the last two decades, more so in urban areas of the sub-continent. Cancer ceters across the country have large numbers of patients being treated with multiple publications in this field. Inspite of paucity of prospective data and randomised clinical trials from India, there are large number of retrospective publications on various aspects of the disease including pathology, radiology, surgery, chemotherapy, radiation, palliative care and alternatitive treatment modalities. These published data provide an insight into the trends of breast cancer in the country and this comprehensive data review of Indian data will provide a basis for designing trials relevant to our population and planning health care.

Adjuvant chemotherapy in soft tissue sarcomas…Conflicts, consensus, and controversies.

Soft tissue sarcomas (STSs) are an uncommon and diverse group of more than 50 mesenchymal malignancies. Each of these histologic subtypes represents a unique disease with distinct biologic behavior and varying sensitivity to chemotherapy. The judicious use of adjuvant/neoadjuvant chemotherapy along with surgery and radiation in the treatment of localized STS has a role in improving patient outcomes by decreasing local and distant recurrences. There is evidence that the use of adjuvant chemotherapy to a mixed cohort of chemo sensitive and insensitive sarcoma subtypes results in limited benefit. Therefore, it is of paramount importance to identify the subpopulation with high metastatic potential and to identify effective histology-specific treatment options to these patients. Present perspective, will focus on the rationale for adjuvant chemotherapy in sarcoma, with emphasis on the histology driven chemotherapy. It will outline key therapeutic opportunities and hurdles in adjuvant medical treatment of sarcoma, focusing on specific subtypes that are on the verge of new breakthroughs, as well as those in which promise has not lived up to expectations.

Practical consensus recommendations on fertility preservation in patients with breast cancer

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Expert oncologists along with reproductive medicine specialists discuss fertility preservation options in this chapter since fertility preservation is becoming a priority for young women with breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Phyllodes tumor of the breast: Wolf inside the sheep’s skin!

Phyllodes tumor, previously known as cystosarcoma phyllodes, is a rare fibro-epithelial tumor of breast constituting <1% of all the breast tumors. It is classified into benign, borderline, and malignant subtypes depending upon the histological criteria defined by the World Health Organization and also has an independent prognostic significance. Accurate pretreatment histological diagnosis is important for the optimal management of phyllodes tumor so that low recurrence rates, improved survival, and optimal long-term cosmetic result can be achieved. Despite surgery being the standard of care, the best type of surgery for each histological type is yet to be defined. The higher rate of local recurrence after surgery alone in borderline and malignant phyllodes tumor raises the question regarding the need of adjuvant treatment, especially radiotherapy, which remains underutilized. The perspective of the current review is to provide the state-of-the-art management of phyllodes tumor of the breast and highlight the risk factors associated with recurrence.

Everolimus in heavily pretreated metastatic breast cancer: Is real world experience different?

BACKGROUND Drugs targeting mammalian target of rapamycin signaling pathway have been recently approved for treatment of hormone receptor (HR) positive metastatic breast cancer (MBC). However, there is lack of real world data from India on the use of this therapeutic strategy. MATERIALS AND METHODS A retrospective analysis of MBC patients who had recurrence or progression while receiving aromatase inhibitors (AIs) and further treated with everolimus and either tamoxifen/AI/fulvestrant between March 2012 and June 2014, was undertaken. RESULTS There were 41 patients with median age 55 years, 73% with visceral metastasis, and 73% with ≥2 sites of metastases. Thirty (73%) patients had received 3 prior lines of therapy including AI (100%), tamoxifen (94%), fulvestrant (39%), and chemotherapy (100%) while the remaining had received <3 lines of prior therapy. The commonest Grade 3/4 adverse events were stomatitis (19%), hyperglycemia (new/worsening, 17%), fatigue (14.5%), nonneutropenic infections (14%), anemia (12%) and pneumonitis (7%). Everolimus dose reductions were required in 31% patients. There were 30% partial responses, 38% prolonged disease stabilizations and 32% disease progression as best responses to everolimus. The median progression-free survival was 22 weeks (5 months). CONCLUSIONS Everolimus based treatment has meaningful activity in heavily pretreated patients with HR-positive MBC but is associated with considerable toxicity and requirement for dose adjustment.