Vikas Ostwal

Role of paclitaxel and platinum-based adjuvant chemotherapy in high-risk penile cancer

Aim: To study the efficacy and safety of paclitaxel and platinum doublet chemotherapy in penile cancer patients with high-risk features of local failure. Materials and Methods: Retrospective analysis was done of patients with 19 carcinoma of the penis who were offered adjuvant chemotherapy with paclitaxel and platinum combination. The data regarding the surgical details, high-risk features for which chemotherapy was offered, chemotherapy toxicity details (in accordance with CTCAE vs 3), failure pattern, and survival data were noted. SPSS version 16 was used for statistical analysis. Descriptive and Kaplan–Meier survival analysis was performed. Results: Median age of patients was 48 years. Fifteen patients received paclitaxel in combination with cisplatin and four received paclitaxel with carboplatin in view of their low serum creatinine clearance. The treatment was completed by 12 patients (63.2%). Of 79 planned cycles, 50 were taken. The treatment was well tolerated with grade 3-4 gastrointestinal toxicity was seen in 1 patient, grade 3 neurological toxicity in one and grade 5 neutropenia in one patient. Treatment related death occured in one patient. The median follow-up was 15.33 months and 6 loco-regional relapsed had taken place. The estimated median DFS was 16.2 months and the estimated median OS was not reached. The estimated DFS for treatment completed patients was 23.13 months as against 2.16 months for patients not completing treatment. Conclusion: The platinum and taxane doublet chemotherapy was found to be safe and effective.

Multidisciplinary management of colorectal adenocarcinoma associated with anal fistula: an Indian series.

Adenocarcinomas associated with anal fistula are rare and often present at an advanced stage. They are often mistaken for commonly occurring benign diseases, leading to delayed diagnosis. Previous reports have predicted inferior oncological outcomes for these cases compared with sporadic rectal cancers. We are presenting our series of patients with colorectal adenocarcinoma associated with anal fistula who were treated with multimodality therapy at a tertiary cancer centre in India.

Primitive neuroectodermal tumor of ovary in a young lady, confirmed with molecular and cytogenetic results--a rare case report with a diagnostic and therapeutic challenge.

Primitive neuroectodermal tumor (PNET) is a small round cell tumor of neuroectodermal origin. It is the most differentiated form of PNET/Ewing’s family of tumors (EFT) [1]. It is the second most common sarcoma among children and usually occurs in the bone and soft tissues [2]. Ewing’s sarcoma/ PNET is characterized by a t (11; 22) (q24; q12) chromosomal translocation that leads to formation of a chimeric transcript EWS-FLI1 in 85% cases, presence of which confirms its diagnosis, especially at non-conventional sites [3]. It has been uncommonly documented at sites other than musculoskeletal system, such as kidneys [4]. PNET has been rarely documented in the female genital system, including ovary, with only few cases confirmed by molecular and / or molecular cytogenetic analysis [5–12]. Herein, we present an uncommon case of PNET involving ovary in a young lady, who presented with a pelvic mass. The diagnostic and therapeutic implications are discussed herewith.

Dihydro pyrimidine dehydrogenase deficiency in patients treated with capecitabine based regimens: a tertiary care centre experience

BACKGROUND Dihydropyrimidine dehydrogenase (DPD) enzyme is the rate limiting step in the metabolism of capecitabine, and its deficiency leads to severe toxicities and rarely, death. METHODS A total of 506 patients were treated in the GI Medical Oncology unit of our institution with capecitabine containing regimens with a dose range of 1,250 to 2,000 mg/m(2)/day during the period from June 2013 to June 2015. Patients with grade (Gr) 3/4 toxicities requiring in-patient care (life threatening complications) were planned for DPD activity testing by peripheral blood PCR sequencing. RESULTS Thirty-one patients developed Gr 3/4 toxicities during cycle 1 of capecitabine. This included mucositis in 24 (77%), diarrhea in 29 (94%), hand-foot syndrome (HFS) in 13 (42%) and myelosuppression in 5 (16%) patients. Twenty-two (81.4%) were found to be DPD deficient with 6 patients negative for DPD mutation. Three patients did not undergo the DPD analysis as advised. More than one mutation was seen in 11 patients. The relative frequencies of the mutations were IVS14+1G→A in 39%, with 13% having homozygosity, 85 T→C in 36%, 1627 A→G in 32%, 496 A→G in 18% and 2194 G→A in 18%, respectively. After dose reduction in cycle 2 in 17 patients of the DPD mutation positive cohort, statistically significant reduction in the toxicities was seen. CONCLUSIONS Dose reduction in DPD deficient patients, reduces risk of life threatening complications significantly but not completely. Upfront screening for DPD deficiency in Indian patients should be evaluated further in view of potentially high homozygous DPD mutation prevalence.

Peritoneal Carcinomatosis in Colorectal Cancers - Management Perspective Needs a Change.

Micro‐Abstract Peritoneal carcinomatosis (PC) from colorectal cancers (CRC) presents a significant treatment challenge. We aimed to find its incidence and outcomes following different treatment modalities. Patients with PC from CRC were included from August 2013 to July 2014 (n = 70). Patients with low peritoneal carcinomatosis index do well. Patients undergoing R0 cytoreduction without hyperthermic intraperitoneal chemotherapy also have better survival. The incidence of PC in CRC is about 10%. Background: Peritoneal carcinomatosis (PC) from colorectal cancers (CRC) either at initial presentation or at subsequent recurrence presents a significant treatment challenge. The aim of our study was to find its incidence and analyze outcomes of patients with PC from CRC origin managed by different treatment modalities. Patients and Methods: A retrospective analysis of patients, from August 2013 to July 2014, presenting with metastatic peritoneal disease from CRC with or without metastasis to other sites was performed. PC was classified as limited (peritoneal carcinomatosis index [PCI] < 10) and widespread (PCI > 10). Results: This study included 70 patients; 45 patients had peritoneum as the only site of metastasis and the remaining 25 visceral metastasis with peritoneum. Resections were performed in 23 patients (19 underwent R0 resection and 4 were R+). All patients received systemic chemotherapy (FOLFOX [Oxaliplatin with fluorouracil and folinic acid]/CAPOX [oxaliplatin and capecitabine]). At a median follow‐up of 11 months, the median OS was 14 months. Patients with PCI < 10 had significantly better survival (median not reached) as compared with those with PCI > 10 (15 months). Patients undergoing R0 resection had better survival (24 months) versus those with R+ resection (16 months). The survival of patients receiving only systemic chemotherapy was 11 months. Conclusion: The incidence of peritoneal metastasis in CRC is about 10%. A select group of patients who have low PCI who undergo R0 resection of only the diseased portion, without entire peritonectomy, still do well. Where facilities for hyperthermic intraperitoneal chemotherapy are not available, cytoreduction followed by systemic chemotherapy should be considered. The added role of hyperthermic intraperitoneal chemotherapy in this subgroup needs to be evaluated.

PET-Based Molecular Imaging in Designing Personalized Management Strategy in Gastroenteropancreatic Neuroendocrine Tumors

In recent years, PET-based molecular functional imaging has been increasingly used in neuroendocrine tumors for tailoring of treatment strategies to the individual characteristics of each patient. For each particular patient, the relative tracer uptake by the dual-tracer PET imaging approach (with 68Ga-DOTANOC/TATE and 18F-FDG) frequently plays an important role along with the histopathologic tumor grades for selecting the optimal treatment approach for advanced/metastatic cases. Various tumor-specific parameters have resulted in development of such precision-medicine type model in this biologically heterogeneous group of tumors. The traditional advantages of PET/computed tomography in terms of disease staging are also applicable for personalization of management. From the medical oncologists standpoint, multitracer PET-based information and staging is of significant importance (in addition to the histologic grades) in selecting the appropriate chemotherapy regimen and monitoring response on an individual basis in the course of treatment.

Pazopanib in metastatic multiply treated progressive gastrointestinal stromal tumors: feasible and efficacious

BACKGROUND A median progression free survival (PFS) of 18-20 months and median overall survival (OS) of 51-57 months can be achieved with the use of imatinib, in metastatic or advanced gastrointestinal stromal tumor (GIST). Sunitinib and regorafenib are approved options for patients progressing on imatinib, but with markedly decreased survival. pazopanib is a broad spectrum TKI targeting KIT, PDGFR and VEGFR receptors and has shown promising activity in phase 2 trials in GIST. METHODS All patients who received pazopanib for GIST between March 2014 and September 2015 in our institution were reviewed. Patients were assessed for response with CT or PET CT scans. Patients continued pazopanib until progression or unacceptable toxicity. Survival was evaluated by Kaplan Meier product method. RESULTS A total of 11 consecutive patients were included in our study. Median duration of follow up was seven months. The median lines of prior therapy was 2 [1-5]. Partial response (PR) was observed in seven patients and two had stable disease (SD). Two patients died within one month of start of pazopanib. Five of ten patients had progressed during the study with eight patients still alive. The median PFS was 11.9 months and the median OS was not reached. Common adverse events seen were hand-foot-syndrome (HFS) in four patients, anemia in four patients and fatigue in three patients. Grade 3/4 adverse events were uncommon. Three patients required dose modification of pazopanib. CONCLUSIONS Pazopanib is a reasonably efficacious well tolerated TKI and can be explored as a treatment option in advanced GIST that has progressed on imatinib.

Emerging role of multimodality treatment in gall bladder cancer: Outcomes following 510 consecutive resections in a tertiary referral center

Gall bladder cancer (GBC) is a disease with high incidence in India. We analyzed the outcomes of patients with suspected GBC who underwent surgical exploration.

Treatment of advanced Gall bladder cancer in the real world—can continuation chemotherapy improve outcomes?

BACKGROUND Gemcitabine-Platinum doublet chemotherapy is the standard of care in patients with locally advanced inoperable and metastatic (LA/M) Gall bladder cancers (GBC). METHODS Consecutive patients with LA/M GBC treated with Gemcitabine-Cisplatin (GC) or Gemcitabine-Oxaliplatin (GO) as first line palliative chemotherapy from January 2013 to June 2015 were retrospectively analysed. Patients who were able to continue chemotherapy beyond 6-8 cycles were separately compared to those who were potential candidates for this approach, but chose not to continue chemotherapy. RESULTS A total of 396 patients received first line palliative chemotherapy during the period of analysis, 276 patients (69.6%) were unable to complete 6-8 cycles of chemotherapy, while 120 patients (30.4%) were potential candidates for continuing chemotherapy. Seventy patients (n=120; 58.3%) received a median of 4 cycles of continuation chemotherapy. Median overall survival (OS) for the entire cohort was 7.65 months [95% confidence interval (CI), -7.14 to 8.16], while median event free survival (EFS) was 4.53 months (95% CI, -4.23 to 4.83). Patients receiving continuation chemotherapy had a statistically improved median OS compared to all other patient cohorts, 14.88 months (95% CI, -12.48 to 17.27; P=0.005 on multivariate analysis). Burden/number of sites of metastases, receiving of continuation chemotherapy, fit and able to receive second line chemotherapy (CT2) were identified on multivariate analysis as prognostic factors for OS. CONCLUSIONS OS in our study appeared lower than published literature, but a group of patients were identified whose survival could be prolonged by continuing chemotherapy. Easily available factors can predict prognosis of GBC undergoing first line palliative chemotherapy.

Erratum to: A Case of Ruptured Adult Embryonal Sarcoma of the Liver with Excellent Outcome After Neoadjuvant Chemotherapy

The original version of this article unfortunately contained a mistake. The age of the patient in the first sentence of the first paragraph under the Case Summary section was incorrectly mentioned as 2 years, which is actually 25 years. The sentence should read: A 25-year-old gentleman with no known medical comorbidities presented to his primary physician with complaints of right hypochondriac pain of 2 months duration.