Rambha Pandey

Targeted therapy of gastrointestinal stromal tumours

Gastrointestinal stromal tumours (GISTs) are mesenchymal neoplasms originating in the gastrointestinal tract, usually in the stomach or the small intestine, and rarely elsewhere in the abdomen. The malignant potential of GISTs is variable ranging from small lesions with a benign behaviour to fatal sarcomas. The majority of the tumours stain positively for the CD-117 (KIT) and discovered on GIST-1 (DOG-1 or anoctamin 1) expression, and they are characterized by the presence of a driver kinase-activating mutation in either KIT or platelet-derived growth factor receptor α. Although surgery is the primary modality of treatment, almost half of the patients have disease recurrence following surgery, which highlights the need for an effective adjuvant therapy. Traditionally, GISTs are considered chemotherapy and radiotherapy resistant. With the advent of targeted therapy (tyrosine kinase inhibitors), there has been a paradigm shift in the management of GISTs in the last decade. We present a comprehensive review of targeted therapy in the management of GISTs.

Adjuvant radiotherapy versus observation following lumpectomy in ductal carcinoma in-situ: A meta-analysis of randomized controlled trials

The role of adjuvant radiotherapy (RT) following lumpectomy for ductal carcinoma in‐situ (DCIS) was addressed in four major randomized controlled trials (RCTs) which were conducted two to three decades ago. Initial results of these trials suggested the protective role of RT in reducing the ipsilateral breast recurrences. Long‐term results of all these four trials, based on more than 10‐years follow‐up data, have recently been published. A meta‐analysis of four published RCTs which have addressed the role of adjuvant RT following lumpectomy for DCIS was conducted. Review manager (Cochrane Collaborations software) version RevMan 5.2 was used for analysis. Evaluated events were ipsilateral breast recurrences (both DCIS and invasive), regional recurrences, contralateral breast events, distant recurrences, and overall mortality. The events were entered as dichotomous variable. The present meta‐analysis included four RCTs and a total of 3680 patients – 1710 received adjuvant RT following lumpectomy while 1970 patients did not receive any adjuvant treatment. Patients who received RT had almost half of risk of ipsilateral breast recurrence (RR = 0.53, 95% CI = 0.45‐0.62) and regional recurrence (RR = 0.54, 95% CI = 0.32‐0.91) compared to those who did not receive adjuvant treatment – there was absolute risk reduction in 15% (95% CI = 12%‐17%) for ipsilateral breast recurrences in adjuvant RT treated patients. There was no significant difference in distant recurrence (RR = 1.06, 95% CI = 0.74‐1.53), contralateral breast events (RR = 1.22, 95% CI = 0.98‐1.52) and overall mortality (RR = 0.93, 95% CI = 0.79‐1.09). Though addition of postoperative RT to lumpectomy does not reduce overall mortality, the present meta‐analysis confirms that it decreases the ipsilateral breast and regional recurrence by almost half.

Report of a unique case of myoepithelial carcinoma of left parotid gland with metachronous bilateral cavernous sinus metastasis

Myoepithelial carcinoma (MC) is a rare, locally aggressive malignant neoplasm of the salivary glands. Only few evidences on its metastatic behavior are available in the literature. We herein present a unique case of MC of left parotid gland which metastasized to bilateral cavernous sinuses. The patient was successfully treated with palliative radiotherapy and chemotherapy.

Crizotinib-Induced Fulminant Hepatic Failure: A Rare Adverse Event

Lung cancer is a leading cause of death with 1.8 million new cases and 1.6 million deaths worldwide in 2012.About 85%arenon–small-cell lung cancer (NSCLC) of which 4% to 7% are positive for anaplastic lymphoma kinase (ALK) gene rearrangement. Patients with ALK gene mutation define a distinct subgroup who are younger, who are light smokers or nonsmokers, and who have adenocarcinoma histology. The tyrosine kinase inhibitor crizotinib significantly improved clinical outcome in patients with ALK-positive advanced NSCLC when compared with conventional chemotherapy and is currently the first line of treatment for these patients. Crizotinib treatment is commonly associated with an increase in liver aminotransferases, which is reversible on dose reduction or interruption. We report a case of crizotinib-induced fulminant hepatic failure with hepatic encephalopathy.

Surgical management of bronchopulmonary carcinoids: A single center experience

Introduction: Bronchopulmonary carcinoids are uncommon tumors with relatively indolent biological behavior but a distinct malignant potential. Surgery is the mainstay of treatment. Our aim was to study preoperative characteristics, surgical approaches, and outcome in patients with bronchopulmonary carcinoid tumors. Patients and Methods: This retrospective study was done in the Department of Surgical Oncology of a Tertiary Teaching Hospital of North India. The case records of all the patients who underwent surgical treatment for lung neoplasms and were diagnosed to have bronchopulmonary carcinoids were reviewed. Details concerning the clinical presentation, preoperative therapy, operative procedure, postoperative complications, and outcome were retrieved from the case records. Results: Sixteen patients who underwent surgical treatment were found to have bronchopulmonary carcinoids on histopathological examination. The median age of the patients was 34 years (range 18–62 years). There were 11 men and five women. All patients were symptomatic, and the median duration of symptoms was 12 months (range 6–72 months) before presentation. Six patients had received antitubercular treatment before presentation, and one patient had been treated with chemotherapy due to misdiagnosis. Surgical procedures included six pneumonectomies (one with carinoplasty), four bilobectomies, three lobectomies, and three bronchoplastic procedures (two with lobectomy and one with bilobectomy). There was no postoperative mortality; three patients had morbidity in the form of lobar collapse, prolonged pleural collection, and surgical site infection. With a median follow-up time of 11 months (range 2–85 months), all the 16 patients are alive and disease-free. Conclusions: Delayed presentation and misdiagnosis of bronchial carcinoid are major concerns in North India. Adequate surgical resection can be performed without undue morbidity and is associated with good long-term results.

Locally advanced carcinoma of the cervix associated with pelvic kidney treated with intensity‐modulated radiotherapy: Overcoming a therapeutic challenge

The simultaneous occurrence of carcinoma of the cervix and pelvic kidney is rare. As the pelvic kidney occupies the conventional radiation portal for carcinoma of the cervix, treatment of these patients with radiation presents a therapeutic challenge. A 48‐year‐old stage IIIB cervical carcinoma patient with an incidental diagnosis of pelvic kidney was treated with radical chemoradiotherapy using intensity‐modulated radiotherapy with concurrent weekly cisplatin, followed by intracavitary radiotherapy. The bilateral kidney dose was restricted within a tolerance limit of 16.6 Gy. At the 18‐month follow‐up, the patient was disease free and had no deterioration in kidney function. Intensity‐modulated radiotherapy provided the necessary means for delivering radical radiation doses in this case scenario with adequate sparing of the kidney.

Malignant solitary fibrous tumor of thoracic spine with distant metastases: Second reported case and review of the literature

Solitary fibrous tumor (SFT) usually originates from the pleura because of abnormal proliferation of fibroblast cells. It is extremely rare for the tumor to originate from the spine. Here, we report the second case of malignant SFT of thoracic spine with distant metastases in a 35-years-old female.

Metabolic toxicities in patients undergoing treatment for nonhematological malignancy: A cross-sectional study.

Objectives: The objective of this study was to evaluate the prevalence of metabolic toxicities in patients with different nonhematological malignancies admitted in oncology ward of a tertiary cancer care center while on treatment. Methods: We did this cross-sectional study over a period of 7 months (January–July 2013) for all adult patients (n = 280) who, while undergoing anti-cancer therapy at our center, got admitted to our oncology inpatient ward with metabolic toxicity. Grading of toxicity was done using National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0. Results: A total of 46 events of metabolic toxicities were noted in 31 patients over this period. The most common of them was hyperglycemia (n = 10). The others were hypokalemia (n = 9), hyponatremia (n = 9), hypernatremia (n = 5), hyperkalemia (n = 5), tumor lysis syndrome (n = 4), hypercalcemia (n = 2), and grade ≤2 hypomagnesemia (n = 2). Majority of the patients were asymptomatic (n = 26). However, death occurred in five patients. Treatment interruptions took place in 19 patients. Age ≤40 years (P = 0.03), Eastern Cooperative Oncology Group performance status ≥2 (P = 0.023), history of addiction (P = 0.02), comorbidities (P = 0.037) were associated with increased risk of having metabolic toxicities on univariate analysis. While on multivariate analysis, only age, performance status, and history of addiction retained their statistical significance. Age ≤40 years (P = 0.02), use of more than one modality of treatment (P = 0.013), and hyperglycemia (P = 0.037) were associated with higher risk of death. Conclusion: Metabolic toxicities are common phenomena among cancer patients, especially those with young age, comorbidities, and having history of addictions. In young age, they might even be fatal, especially when they are treated with combined modality of treatment.

Diabetes Cured by Pancreaticoduodenectomy: A Case Report of Glucagonoma Masquerading as Carcinoma of the Head of Pancreas.

The association between carcinoma of the pancreas and diabetes mellitus is well recognized [1–3]. This diabetes may also be a manifestation of a functional endocrine tumor of the pancreas. We report a diabetic patient who presented with obstructive jaundice and was diagnosed to have carcinoma of the pancreatic head. She underwent pancreaticoduodenectomy following which her diabetes got cured. The histopathology report revealed a malignant endocrine tumor in the pancreatic head with lymph nodal metastases.