Nilesh Sable

Gnathic Osteosarcoma: Clinical, Radiologic, and Pathologic Review of Bone Beard Tumor

Gnathic (mandibular) osteosarcomas (OSs) account for approximately 6.5% of all OS, and most of them are secondary in nature, occurring in patients with Paget disease or fibrous dysplasia or as a late sequela to craniofacial radiotherapy. Primary OS of the jaw is rare and presents approximately two decades later than its appendicular counterpart; metastasis is uncommon with primary OS, and it has a better prognosis than appendicular OS. Radiologic depiction of a sunburst pattern of new bone formation is characteristic. Early diagnosis and complete tumor resection are mandatory to improve the prognosis of jaw OS.

Efficacy and safety of sorafenib in advanced renal cell cancer and validation of Heng criteria

INTRODUCTION Sorafenib is an established upfront treatment option for metastatic RCC (mRCC). There is no published literature regarding its performance in Indian Patients. We present an analysis of Sorafenib use in our institute and attempt to validate the Heng criteria as a prognostic score in these patients. MATERIALS AND METHODS Patients who received Sorafenib as first line treatment for advanced RCC from June 2012 to December 2015 were prognosticated by Heng criteria and retrospectively analysed for baseline demographics, toxicity, response and outcomes. RESULTS 82 patients (65 males, 17 females) with a median age of 57 years were included for final analysis. Median ECOG PS was 1, 95.2 % of the patients had Stage IV disease and clear cell was the predominant histology (79.4%). 23.2%, 42.7% and 34.1% of patients were classified as low, intermediate and high risk by Hengs criteria, respectively. Dose reduction was required in 24.4% of patients, while 14.6% required permanent cessation of Sorafenib due to intolerable or recurrent side effects. Common adverse events included HFS (68.2%), mucositis (35.3%), fatigue (35.3%), rash (32.9%) and hypertension (25.6%). Response rate observed was 18.2%, while clinical benefit rate was 57.2% in the 57 patients where response was evaluable. Median progression free survival was 7.75 months (5.45-10.05) and median overall survival (OS) was 12.18 months (9.61 - 14.76). Median OS was 19.6, 16.1 and 10.3 months respectively for low, intermediate and high risk patients by Heng criteria and the criteria was statistically discriminatory for the 3 groups for OS (p=0.045, chi-square test). CONCLUSION Sorafenib is a viable upfront treatment option for metastatic RCC in Indian patients with acceptable PFS, although a high incidence of HFS, mucositis and rash is observed. The Heng score has discriminatory value in mRCC with Sorafenib and can be considered for routine use in the clinic.

Patterns of care and outcomes for second-line targeted therapy in metastatic renal cell carcinomas: A registry based analysis.

AIM Patterns of care for metastatic renal cell carcinomas (mRCC) have seen tremendous reform in the last decade. Here, we present our pattern of care in second-line targeted therapy for mRCC. METHODS Patients with mRCC treated with second-line therapy were included from a prospective database. Demographics, risk stratification, and treatment details were noted. Event-free survival (EFS) and overall survival (OS) was calculated using Kaplan-Meier method. Log-rank test was used to identify factors affecting EFS and OS. Multivariate analysis was performed using cox regression. RESULTS Nearly 21.7% (46/212) of patients received second-line targeted treatment. Heng score for risk stratification showed 21.7% of patients in low risk, 36.9% in intermediate, and 34.8% in high risk group. Everolimus followed by pazopanib were the most common second-line therapies used in 65.2% and 13% of patients, respectively. The estimated median EFS was 3.5 months (95% confidence interval [CI] 2.7-4.26 months) and estimated median OS from the start of second-line therapy was 6.2 months (95% CI 3.4-9.0 months) with a median follow-up of 4.3 months. On univariate log-rank analysis, EFS of more than 6 months with first-line therapy was associated with improvement in EFS with second-line therapy (9.5 vs. 2.0 months; hazard ratio (HR) 0.364; P = 0.002). There was no factor independently associated with EFS or OS on multivariate analysis. CONCLUSION Patterns of care for second line targeted therapy tend to vary with setting. A longer EFS with first-line therapy predicts improved outcomes with second-line treatment.

Solitary Osseous Metastasis of Rectal Carcinoma Masquerading as Osteogenic Sarcoma on Post-Chemotherapy Imaging: A Case Report

Solitary metastases from colorectal carcinoma in the absence of hepatic or pulmonary metastases are rare. These can have a diverse imaging appearance, particularly after chemotherapy. It is important identify patients with solitary skeletal metastases, as they have a better prognosis than those with multiple skeletal or visceral metastases. We describe an unusual case of a solitary metastasis to the femur in a case of colon carcinoma that went undiagnosed and later presented with imaging features of osteogenic sarcoma.

Treatment outcomes of metastatic nonclear cell renal cell carcinoma: A single institution retrospective analysis

Introduction: Nonclear cell (NCC) metastatic renal cell carcinoma (mRCC) is a biologically heterogeneous entity. We report the outcomes of NCC mRCC treated with first-line vascular endothelial growth factor (VEGF) inhibitors or mammalian target of rapamycin (mTOR) inhibitors at our institute. This is first such report from India. Methods: This is a retrospective analysis of the 40 consecutive patients of NCC mRCC treated between January 2013 and June 2015 in routine clinical practice at our institute. The primary endpoint analyzed was overall survival (OS) with respect to the type of first-line treatment and tumor histology. Results: The most common histological subtype was papillary in 25 patients (62.5%) followed by sarcomatoid in six (15%), chromophobe in 5 (12.5%), translocation-associated in one patient, and other nonspecified in three patients. First-line treatment was sorafenib in 14 (35%), sunitinib in 9 (22.5%), pazopanib in 8 (20%), everolimus in seven (17.5%), and best-supportive care (BSC) in two (5%) patients. Partial response, stable disease, and progression was observed in six (15%), 13 (32.5%), and nine (22.5%) cases, respectively, as the best response to first-line treatment. The median OS was 11.7 months and median event-free survival was 6.1 months in the whole cohort. The median OS in months for different first-line treatments were as follows: sorafenib (16.2), sunitinib (11.7), pazopanib (not reached, mean-23.9 ± 6.0), everolimus (4.1) and BSC (0.6) and for different histological subtypes were as follows: papillary (9.8), chromophobe (not reached, mean-30.3 ± 8.4), sarcomatoid (4.1), and others (7.9). Conclusions: Chromophobe histology has a better outcome compared to other histological subtypes, and anti-VEGF tyrosine kinase inhibitors are preferable first-line agents compared to mTOR inhibitors.

Radiomics based detection and characterization of suspicious lesions on full field digital mammograms

BACKGROUND AND OBJECTIVE Early detection is the important key to reduce breast cancer mortality rate. Detecting the mammographic abnormality as a subtle sign of breast cancer is essential for the proper diagnosis and treatment. The aim of this preliminary study is to develop algorithms which detect suspicious lesions and characterize them to reduce the diagnostic errors regarding false positives and false negatives. METHODS The proposed hybrid mechanism detects suspicious lesions automatically using connected component labeling and adaptive fuzzy region growing algorithm. A novel neighboring pixel selection algorithm reduces the computational complexity of the seeded region growing algorithm used to finalize lesion contours. These lesions are characterized using radiomic features and then classified as benign mass or malignant tumor using k-NN and SVM classifiers. Two datasets of 460 full field digital mammograms (FFDM) utilized in this clinical study consists of 210 images with malignant tumors, 30 with benign masses and 220 normal breast images that are validated by radiologists expert in mammography. RESULTS The qualitative assessment of segmentation results by the expert radiologists shows 91.67% sensitivity and 58.33% specificity. The effects of seven geometric and 48 textural features on classification accuracy, false positives per image (FPsI), sensitivity and specificity are studied separately and together. The features together achieved the sensitivity of 84.44% and 85.56%, specificity of 91.11% and 91.67% with FPsI of 0.54 and 0.55 using k-NN and SVM classifiers respectively on local dataset. CONCLUSIONS The overall breast cancer detection performance of proposed scheme after combining geometric and textural features with both classifiers is improved in terms of sensitivity, specificity, and FPsI.

Case of victims of modern imaging technology: Increased information noise concealing the diagnosis

We present a case of tubercular arthritis who underwent numerous unnecessary investigations what is known as “victims of modern imaging technology” or VOMIT. Today there is an exponential rise in the volume of the medical imaging, part of which is contributed by unnecessary and unjustified indications. We discuss about the untoward effects of the uninhibited and careless use of modern imaging modalities and possible ways to avoid. Skeletal manifestation of the tuberculosis is still common in the endemic countries like India. Although the final diagnosis of the skeletal tuberculosis like tubercular arthritis is made by bacteriological and histological studies, few demographic, clinical and radiological features might help making early diagnosis.

Magnetic Resonance Imaging of Gynecological Malignancies: Role in Personalized Management

Gynecological malignancies are a leading cause of mortality and morbidity in women and pose a significant health problem around the world. Currently used staging systems for management of gynecological malignancies have unresolved issues, the most important being recommendations on the use of imaging. Although not mandatory as per the International Federation of Gynecology and Obstetrics recommendations, preoperative cross-sectional imaging is strongly recommended for adequate and optimal management of patients with gynecological malignancies. Standardized disease-specific magnetic resonance imaging protocols help assess disease spread accurately and avoid pitfalls. Multiparametric imaging holds promise as a roadmap to personalized management in gynecological malignancies. In this review, we will highlight the role of magnetic resonance imaging in cervical, endometrial, and ovarian carcinomas.

Use of ultrasound imaging for the diagnosis of abnormal uterine bleeding in the bonnet macaque (Macaca radiata)

Ultrasound is a powerful, low-cost, non-invasive medical tool used by laboratory animal veterinarians for diagnostic imaging. Sonohysterography and transvaginal ultrasound are frequently used to assess uterine anomalies in women presenting with abnormal uterine bleeding (AUB). In the present study, we have evaluated the abdominal ultrasound of bonnet monkeys (n = 8) showing spontaneous ovulatory (n = 5) and anovulatory (n = 3) AUB. The ovulatory (n = 5) macaques showed cyclic AUB for 7–8 days. The anovulatory (n = 3) macaques had irregular AUB with menstrual cycles of 40–45 days. The B-mode abdominal, colour Doppler and 3D ultrasound scans were performed during the proliferative phase of the menstrual cycle. Ultrasound examination revealed endometrial polyps in five macaques and endometrial hyperplasia in three animals. The width and length of endometrial polyps was around 0.5–1 cm (average 0.51 ± 0.23 cm × 0.96 ± 0.16 cm) with significant increase in endometrial thickness (P < 0.0002). 3D ultrasound also showed a homogeneous mass in the uterine cavity and colour Doppler ultrasound showed increased vascularity in the endometrial polyps. Endometrial hyperplasia characteristically appeared as a thickened echogenic endometrium (P < 0.0002). This study demonstrates the use of non-invasive ultrasound techniques in the diagnosis of AUB in macaques.

Atypical T1 Hyperintense Neurocysticercosis Masquerading As Cystic Brain Metastases

Neurocysticercosis (NCC) is a clinical condition characterized by involvement of the CNS by an encysted larval form of the parasite Taenia solium. It is a common cause of seizures and neurologic morbidity in developing countries. Brainmetastasis is a common complication of cancer, and cystic brain lesions often pose a diagnostic challenge in this clinical scenario. The imaging appearance of NCC onmagnetic resonance imaging (MRI) depends on the stage of the disease. To our knowledge, cystic lesions in NCC appearing hyperintense on T1-weighted, T2-weighted, and fluid-attenuated inversion recovery (FLAIR) images have not been described in the literature. We report one such a case, with multiple intracranial cystic lesions showing hyperintense signals on T1-weighted images.