Seema Medhi

Evaluation of diffusion-weighted imaging as a predictive marker for tumor response in patients undergoing chemoradiation for postoperative recurrences of cervical cancer

PURPOSE To investigate diffusion-weighted imaging (DWI) as a response biomarker in patients undergoing chemoradiation for postoperative recurrences of cervical cancer. MATERIALS AND METHODS From October 2008 to March 2011, 20 patients were included. All underwent T2-weighted (T2W) and DWI before and after chemoradiation. Gross tumor volume (GTV), lateral extent, apparent diffusion coefficient (ADC), and presence of regions of focally restricted diffusion were determined at baseline. Response to chemoradiation was categorized as either partial or complete. Receiver operator characteristics (ROC) curve identified thresholds of GTV and ADC that best predict for partial response. Univariate and multivariate analysis were performed on SPSS version 15. RESULTS The median GTV was 24.5 cc (4.1-110 cc). Central and lateral disease was present in 8 and 12 patients, respectively. The median ADC was 1 × 10 -3 mm² /s (0.8-1.3 × 10⁻³ mm² /s) and 12/20 (60%) patients had focal restricted diffusion. Overall 10/20 patients had partial response. ROC analysis identified volume of 25 cc or higher [sensitivity = 80%, specificity = 80%, area under curve (AUC) = 0.76, P = 0.04] and ADC more than 1 × 10⁻³ mm² /s (sensitivity = 70%, specificity = 50%, AUC = 0.62; P = 0.34) to best predict for partial response. On univariate analysis bulky disease (77.7% vs. 27%; P = 0.03), lateral disease (66.6% vs. 25%; P = 0.08), and focal regions of restricted diffusion (66.6% vs. 25%; P = 0.06) predicted for partial response to chemoradiation. All factors continued to be significant on multivariate analysis. On restricting analysis to bulky tumors ADC greater than 0.95 × 10⁻³ mm² /s predicted partial response with high sensitivity (85.7%) and specificity (100%) (AUC 0.96; P = 0.05). On univariate analysis lateral disease (P = 0.04), high baseline ADC (P = 0.07) predicted for partial response. CONCLUSIONS Baseline ADC and focal regions of ADC restriction predict for partial response with moderate sensitivity and specificity in patients with postoperative recurrences of cervical cancer and need to be validated in larger cohort.

Prognostic Factors and Outcome in Askin-Rosai Tumor: A Review of 104 Patients

PURPOSE To evaluate the prognostic factors and treatment outcome of patients with Askin-Rosai tumor of the chest wall treated at a single institution. METHODS AND MATERIALS Treatment comprised multiagent chemotherapy and local therapy, which was either in the form of surgery alone, radical external-beam radiotherapy (EBRT) alone, or a combination of surgery and EBRT. Thirty-two patients (40%) were treated with all three modalities, 21 (27%) received chemotherapy and radical EBRT, and 19 (24%) underwent chemotherapy followed by surgery only. RESULTS One hundred four consecutive patients aged 3-60 years were treated at the Tata Memorial Hospital from January 1995 to October 2003. Most (70%) were male (male/female ratio, 2.3:1). Asymptomatic swelling (43%) was the most common presenting symptom, and 25% of patients presented with distant metastasis. After a median follow-up of 28 months, local control, disease-free survival, and overall survival rates were 67%, 36%, and 45%, respectively. Median time to relapse was 25 months, and the median survival was 76 months. Multivariate analysis revealed age ≥18 years, poor response to induction chemotherapy, and presence of pleural effusion as indicators of inferior survival. Fifty-six percent of patients with metastatic disease at presentation died within 1 month of diagnosis, with 6-month and 5-year actuarial survival of 14% and 4%, respectively. CONCLUSION Primary tumor size, pleural effusion, response to chemotherapy, and optimal radiotherapy were important prognostic factors influencing outcome. The combination of neoadjuvant chemotherapy, surgery, and radiotherapy resulted in optimal outcome.

Primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old woman: a case report

IntroductionPrimary Ewings sarcoma or primitive neuroectodermal tumor of the genital tract of women is uncommon. Rarer still is its occurrence in the vagina, with only five cases described so far. Out of these, only one case was confirmed using molecular analysis.Case presentationWe present an extremely rare case of Ewings sarcoma or primitive neuroectodermal tumor in a 17-year-old Indian girl. She presented with a vaginal mass that was initially diagnosed as a malignant round cell tumor. Immunohistochemistry showed diffuse positivity for vimentin, membranous positivity for MIC2, and positivity for BCL2 and FLI-1. On the other hand, she was negative for cytokeratin, epithelial membrane antigen, desmin, Myo D-1, myogenin and smooth muscle actin. A diagnosis of primitive neuroectodermal tumor was thus offered. Furthermore, a molecular analysis of our patient using reverse transcription-polymerase chain reaction technique showed positivity for t(11; 22) (q24; q12) (EWSR1-FLI1), thus confirming the diagnosis of a Ewings sarcoma/primitive neuroectodermal tumor. Our patient was offered chemotherapy on Institutional protocol EFT 2001.ConclusionThis is a rare case of primary vaginal Ewings sarcoma or primitive neuroectodermal tumor, which was confirmed with molecular analysis, in the youngest patient known so far. This study reinforces the value of integrating morphological features with membranous MIC2 positivity, along with application of molecular techniques in objective identification of an Ewings sarcoma or primitive neuroectodermal tumor at uncommon sites.

18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/ computerized tomography study

Leptomeningeal metastases (LM) are most commonly observed in hematological malignancies. With prolonged survival in solid tumors, an increased frequency of metastases is noted in these tumors too. Early diagnosis, when the patient has minimal neurological disability, is associated with prolonged survival and improved functional outcome although the therapy is palliative. The diagnosis of LM is difficult, and the demonstration of tumor cells in the cerebrospinal fluid remains the gold standard. This can also be done by definitive neuroimaging. MRI is routinely used in this aspect. We discuss here a case where 18F-FDG PET/CT (Fluoro-de-oxy glucose positron emission tomography/computerized tomography) study helped us in the diagnosis of LM. Whole-body PET/CT imaging could be a useful tool in identifying the possibility of metastases of breast carcinoma in the usual sites and the not-so-usual sites of metastases.

Calvarial metastasis of a renal cell carcinoma, mimicking a primary alveolar soft part sarcoma, in a young girl-a rare case report.

Renal cell carcinoma (RCC) is characterized by an unpredictable clinical behavior. It has a tendency for early metastasis, which, at times is the initial presentation and therein poses a diagnostic challenge. We present a rare case of a disseminated RCC in a 15-year-old girl, who primarily presented with an occipital soft tissue mass. Computed tomography (CT) of the head revealed a soft tissue mass in the scalp, eroding the occipital bone and extending intracranially. Biopsy examination showed overlapping features of an alveolar soft part sarcoma (ASPS) and a RCC. Immunohistochemistry (IHC) showed diffuse positivity for CD10 and focal positivity for vimentin. Cytokeratin (CK) and epithelial membrane antigen (EMA) were negative. The patient was recommended a clinical ‘work-up’ to rule out a possible primary in the kidneys. Her CT scan abdomen unraveled a large, lobulated, heterogeneous cystic mass, involving the middle and upper pole of the left kidney. Diagnosis of a metastatic RCC was ascertained. The present case represents a rare manifestation of a RCC metastasizing at an unusual location i.e. calvarium in the youngest patient known, so far and masquerading a primary ASPS. It also highlights the value of clinico-patho-radiological correlation, including CD10 as a useful IHC marker in diagnosing a RCC in young patients, especially when histopathological features overlap with ASPS.

Large adrenal ganglioneuroma with left inferior vena cava: implications for surgery

The contemporaneous occurrence of adrenal ganglioneuroma and left-sided inferior vena cava is uncommon and is previously never reported. We present a case wherein the two entities were fortuitously associated on preoperative imaging. This information facilitated successful surgical resection and avoided catastrophic vascular injury. A review of literature of the common venous anomaly affecting therapeutic decision-making is also presented.

Successful management of multi-focal hepatic infantile hemangioendothelioma using TACE/surgery followed by maintenance metronomic therapy.

Infantile hepatic hemangioendothelioma (IHE) is a rare angiogenic tumour with diverse clinical presentations and varied course ranging from spontaneous regression to life-threatening complications. The authors report a 2-year boy who presented with respiratory distress and was identified as a case of inoperable multi-focal hepatic IHE. He showed a transient response to trans-arterial-chemo-embolisation and liver resection but had progressive disease despite chemotherapy (prednisolone/vicristine/ifosfamide/cisplatin). Thereafter, he was successfully managed with metronomic therapy using cyclophosphamide and tamoxifen.

Unicystic ameloblastoma of the mandible masquerading as carcinoma of the oral cavity in a 10-year-old girl

A case of unicystic ameloblastoma of the mandible in a 10-year-old child is described. In addition to the mandibular swelling the patient also had a proliferative lesion over the alveolus that masqueraded as a neoplastic lesion.

Quantitative estimation of doses to salivary glands from using brachytherapy in head and neck cancers

PURPOSE To quantify the percentage doses received by salivary glands (SGDs) in head and neck interstitial brachytherapy (BT). METHODS AND MATERIALS The study included 43 patients who underwent high-dose rate iridium-192 implant for oral cavity and oropharyngeal lesions treated with BT as a boost. BT dose varied with disease stage and external radiation dose, with the total mean dose of 66±4Gy. Patients were divided into two groups, midline and lateralized, based on anatomic implant location. Different dose parameters such as D(max), D(mean), DV(30%) of individual glands were derived from dose volume histogram representing the percentage maximum dose, mean dose, and dose received by 30% volume of individual SGDs, respectively. For better perception of the impact of BT on individual SGDs, the doses received are extrapolated to radical BT dose of 60Gy. RESULTS For lateralized implants, the highest dose received by ipsilateral parotid (PTD) was 12.3% seen in tonsillar implants. The contralateral PTD receives minimal doses. As expected, the ipsilateral submandibular gland (SMG) received high doses in the range of 80% of the total prescribed dose, whereas contralateral SMG received 10% of ipsilateral dose. For the midline implants, the mean dose range for PTD was 7-11% of the total prescribed dose and for SMG between 17% and 56%, depending on the location. CONCLUSIONS The study quantifies the percentage doses received by the individual SGDs in interstitial head and neck BT for use in future planning of the BT procedures and for salivary functional studies, prediction of damage, and quality-of-life parameters.

Internal target volume for post-hysterectomy vaginal recurrences of cervical cancers during image-guided radiotherapy

OBJECTIVE The outcome of post-surgical recurrences of cervical cancer may be improved through radiation dose escalation, which hinges on accurate identification and treatment of the target. The present study quantifies target motion during course of image-guided radiotherapy (IGRT) for vault cancers. METHODS All patients underwent planning CT simulation after bladder-filling protocol. A daily pre-treatment megavoltage CT was performed. All translations and rotations were recorded. Post-registration displacement of gross tumour volume (GTV) and centre of mass (COM) of GTV was independently recorded by two observers for fractions one to seven. Day 1 image sets served as reference images against which the displacements of COM were measured. We calculated the displacements of common volume (CV) and encompassing volume (EV) of GTV for both the observers. RESULTS A total of 90 image data sets of 15 patients were available for evaluation. Individual patient GTV and average GTV by both the observers were comparable. The average shifts for EV were 2.4 mm [standard deviation (SD) ±1.2] in the mediolateral, 4.2 mm (SD ±2.8) in the anteroposterior and 4.0 mm (SD ±2.1) in superoinferior directions. Similarly, the average shifts for CV were 1.9 mm (SD ±0.6) in the mediolateral, 3.7 mm (SD ±2.7) in the anteroposterior and 4.4 mm (SD ±2.7) in superoinferior directions. Using Strooms/van Herks formula, the minimum recommended margins would be 4.5/5.2, 8.2/9.4 and 7.3/8.3 mm, respectively, for lateral, anteroposterior and superoinferior directions. CONCLUSION Differential directional internal margin is recommended in patients undergoing IGRT for post-surgical recurrence of cervical cancers. ADVANCES IN KNOWLEDGE Internal organ motion of vault cancers can be accounted for by a directional margin to the gross tumour.