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   Table of Contents - Current issue
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April-June 2022
Volume 59 | Issue 2
Page Nos. 157-306

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EDITORIAL  

Cancer research in lower- and middle-income countries (LMICs): How can we improve? p. 157
Amol Akhade
DOI:10.4103/ijc.ijc_662_22  PMID:35946181
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REVIEW ARTICLES Top

Oral and dental care before radiotherapy: Guidelines and development of a time-bound protocol p. 159
Sudhir Bhandari, Bhavita W Soni, Ankush Jamwal, Sushmita Ghoshal
DOI:10.4103/ijc.IJC_871_20  PMID:35946182
Involvement of multidisciplinary team is the mainstay in the holistic treatment outcome in head and neck cancer patients. Achieving a state of oral health is regarded as an essential treatment goal before radiation therapy but, it may get overlooked due to many competing priorities, lack of multidisciplinary facilities and/or incoordination, and limited overall awareness with regards to means of achieving oral health and in a time-bound manner and its relevance in improving quality of life in cancer survivors. Radiation inflicts an immense amount of damage upon the entire maxillofacial complex and consequently oral treatment after radiotherapy may remain untreated and/or undertreated. It is, therefore, vital to eliminate oral foci of infections well within a time frame before radiation so that tumor prognosis is not compromised.This article describes the current guidelines combined with a time-bound protocol developed in our center to not only prepare a patient for conventional radiotherapy but also to provide a logical perspective towards the feasibility of the oral rehabilitation post-cancer cure. The protocol aims to maximize the quality of life in head and neck cancer survivors by; patient education, minimizing preventable oral complications, and retaining strategic teeth for function, aesthetics, speech, and prosthetic support. The time-bound pre-radiation oral care protocol is rational, achievable, and is aligned towards the sustained oral health care goals in head and neck cancer patients and can be utilized as a useful resource in multidisciplinary head and neck cancer care facilities.
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Adjuvant versus early Salvage radiation therapy for prostate cancer with adverse pathological features on radical prostatectomy—Do we finally have an answer? p. 170
Saurabh Jain, Indranil Mallick, Ashwin Sunil Tamhankar, Gagan Gautam
DOI:10.4103/ijc.IJC_516_20  PMID:35946183
Background: The presence of adverse pathological features like extraprostatic extension, seminal vesicle involvement, or positive margins at radical prostatectomy incurs a high risk of postoperative recurrence. Currently, adjuvant radiotherapy (ART) is the standard of care in these patients, while early salvage radiotherapy (eSRT) is a potential alternative strategy. Aims: The purpose of this paper is to review the latest evidence comparing outcomes of adjuvant versus early SRT in this clinical scenario. Materials and Methods: A systematic review of Google Scholar, PubMed/Medline, and EMBASE was done to identify relevant studies published in the English language, regarding outcomes of adjuvant radiotherapy and early SRT in post radical prostatectomy patients. Twelve studies, including six randomized trials, four retrospective studies, one systematic review, and one metanalysis were included in the final analysis. Results: We found that initial randomized trials demonstrated better event-free survival with adjuvant radiotherapy when compared to observation alone. However, ART was associated with increased risk of overtreatment and thus increased radiation-related toxicity rates. Conclusion: Preliminary evidence from recently reported RCTs suggests that eSRT may provide equivalent oncological outcomes to ART in prostate cancer patients with adverse pathology on radical prostatectomy while decreasing unnecessary treatment and radiation-related toxicity in a significant proportion of patients. However, the final verdict would be delivered after the long-term metastasis-free survival and overall survival outcomes are available.
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ORIGINAL ARTICLES Top

Evaluation of acute hematological toxicity by machine learning in gynecologic cancers using postoperative radiotherapy p. 178
Melek Akcay, Durmus Etiz, Ozer Celik, Alaattin Ozen
DOI:10.4103/ijc.IJC_666_19  PMID:34380848
Background: The aim of the study is to investigate the factors affecting acute hematologic toxicity (HT) in the adjuvant radiotherapy (RT) of gynecologic cancers by machine learning. Methods: Between January 2015 and September 2018, 121 patients with endometrium and cervical cancer who underwent adjuvant RT with volumetric-modulated arc therapy (VMAT) were evaluated. The relationship between patient and treatment characteristics and acute HT was investigated using machine learning techniques, namely Logistic Regression, XGBoost, Artificial Neural Network, Random Forest, Naive Bayes, Support Vector Machine (SVM), and Gaussian Naive Bayes (GaussianNB) algorithms. Results: No HT was observed in 11 cases (9.1%) and at least one grade of HT was observed in 110 cases. There were 55 (45.5%) cases with ≤grade 2 HT (mild HT) and 66 (54.5%) cases with grade ≥3 HT (severe HT). None of the patients developed grade 5 HT. Of 24 variables that could affect acute HT, nine were determined as important variables. According to the results, the best machine learning technique for acute HT estimation was SVM (accuracy 70%, area under curve (AUC): 0.65, sensitivity 71.4%, specificity 66.6%). Parameters affecting hematologic toxicity were evaluated also by classical statistical methods and there was a statistically significant relationship between age, RT, and bone marrow (BM) maximum dose. Conclusion: It is important to predict the patients who will develop acute HT in order to minimize the side effects of treatment. If these cases can be identified in advance, toxicity rates can be reduced by taking necessary precautions. These cases can be predicted with machine learning algorithms.
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Quality of life and burden in family caregivers of patients with advanced cancer receiving specialized palliative care p. 187
Nesteren Koçak, Gülçin Şenel, Gonca Oğuz, Şerife Karaca, Fatih Gökse
DOI:10.4103/ijc.IJC_671_19  PMID:33753604
Background: The caregivers of advanced cancer patients face many physical, psychological, social, and economic problems. In this study, the quality of life and burden in the primary family caregiver of patients with advanced cancer receiving inpatient palliative care were investigated. Methods: A total of 200 patients with advanced cancer hospitalized at palliative care center and primary caregivers were included. Functional capacities of patients were evaluated with Karnofsky Performance Scale and need of care with Katz index. The Turkish version of World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF TR) was used to assess the quality of life of caregivers. Results: The median Karnofsky Performance score of patients was found to be 30% and Katz Index score to be 2. The mean WHOQOL-BREF TR domain scores of family caregivers were 48.96 (Standard deviation (SD) =12.67) for physical health, 59.21 (SD=14.09) for psychological status, 56.83 (SD=20.91) for social relations, and 55.67 (SD=14.13) for environmental domain. Scores of psychological and environmental subscales were lower in women caregivers. The environmental subscale showed a significant difference in terms of education. The score of social relations subscale of the care giving spouse was lower than caregiving children and siblings. The score of environmental subscale of caregivers with insufficient income was found to be lower than caregivers with sufficient income. Karnofsky Performance and Katz Index scores and subscales of WHOQOL-BREF TR did not reveal any significant relation. Conclusion: This study showed that all subscales of quality of life are impaired in caregivers of advanced cancer patients, physical health being the most prominent.
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Power Doppler sonography – A supplement to hysteroscopy in abnormal uterine bleeding: Redefining diagnostic strategies p. 194
Shuchita Batra, Anuradha Khanna, RC Shukla
DOI:10.4103/ijc.IJC_676_19  PMID:33753626
Background: Abnormal Uterine Bleeding (AUB) is a very frequent cause of gynecological visits in women of all age groups. Ultrasound pelvis with or without endometrial sampling have been conventionally used to make diagnosis. Power Doppler is a comparatively recent modality which can be used to screen patients who will need endometrial biopsy/ curretage. We hereby conducted a study to compare the diagnostic accuracy of power Doppler sonography and hysteroscopy with histopathology associated with abnormal uterine bleeding. We also calculated the incidence of uterine pathology in AUB by power Doppler ultrasound and hysteroscopy and compared it with histopathology. Methods: This prospective cohort study was conducted at the Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University. After excluding 42 women, a total of 100 women fulfilling the inclusion criteria contributed to our study. Selected women underwent power Doppler ultrasound and hysteroscopy with guided biopsy. Results were compared with histopathology as per the gold standard. Evaluation of sensitivity, specificity, positive and negative predictive values were performed for each modality. All statistical analyses were performed using the SPSS 11.0 statistical package. P value ≤0.05 was considered statistically significant for all tests used. Results: Sensitivity and specificity of power Doppler are 75% and 100% for carcinoma endometrium, 72.72% and 98.9% for endometrial hyperplasia, and 81.81% and 100% for endometrial polyp, respectively. Conclusion: Power Doppler sonography can be used to screen outpatients who do not need an endometrial biopsy for abnormal uterine bleeding. This will avoid unnecessary hysteroscopy in definitive benign cases, and watchful hysteroscopy in suspected premalignant and malignant cases. Irregular branching vessels and color splashes were found to be the best parameters for diagnosing endometrial carcinoma. Power Doppler should be done along with transvaginal sonography in all cases of abnormal uterine bleeding.
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Feasibility and impact of screening for venous thromboembolism in treatment-naive lung cancer patients–Results of a prospective cohort study p. 203
Valliappan Muthu, Ramesh L Narasimhan, Kuruswamy T Prasad, Jasmina Ahluwalia, Mandeep Garg, Digambar Behera, Navneet Singh
DOI:10.4103/ijc.IJC_678_19  PMID:33753627
Background: Venous thromboembolism (VTE) in cancer remains underdiagnosed. This prospective study aimed to evaluate the feasibility of screening for VTE in lung cancer (LC) patients. We assess the incidence of VTE, its risk factors, and effects on overall survival (OS). Methods: Consecutive treatment-naive LC patients were screened for deep venous thrombosis (DVT) with compression ultrasonography and pulmonary thromboembolism (PTE) with computed tomography pulmonary angiography (CTPA) at diagnosis and after 3 months of treatment. The incidence rate of VTE (DVT and/or PTE) was calculated. Risk factors associated with VTE were assessed using logistic regression analysis. All participants were followed-up to 1 year after enrollment. OS was compared in LC subjects with and without VTE, using the Cox proportional hazard analysis. Results: Around 301 subjects with LC (stages IIIB-IV accounted for 83.1%) were enrolled, of which 16 had VTE (5.3%). The incidence rate of VTE was 90 per 1000 person-years (PY). PTE was asymptomatic in 27.3% of cases while all DVT episodes were symptomatic. The incidence rate of asymptomatic PTE identified during the screening was 17 per 1000 PY. The median duration from LC diagnosis to the VTE event was 96.5 days. Median OS was significantly less in VTE patients [161 versus 311 days; P = 0.007] and death was attributable to VTE in 50%. After adjusting for covariates, VTE (hazard ratio [HR] = 2.1), smoking (HR = 1.7), and Eastern cooperative oncology group performance status ≥2 (HR = 1.6) were independently associated with poor OS in LC. Conclusions: VTE occurs in approximately 1 in 20 newly-diagnosed patients with LC and is associated with decreased OS. Screening for PTE may be considered even in resource-limited settings.
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Factors predicting contralateral nodal spread in papillary carcinoma of thyroid p. 212
Harish Verma, Nija Shah, Prateek Jain, Kapila Manikantan, Rajeev Sharan, Pattatheyil Arun
DOI:10.4103/ijc.IJC_684_19  PMID:33753605
Background: Lymph node metastasis (LNM) is evident in about 20–50% of cases at presentation in papillary carcinoma thyroid (PTC). There are no clear recommendations for the need and extent of lateral and central compartment dissection in PTC. Methods: A total of 83 patients who underwent total thyroidectomy and bilateral selective neck dissection for diagnosed PTC from September 2011 to October 2017 were retrospectively analyzed. Results: Tumor site was bilobar or involving isthmus in 40 patients. Contralateral LNM was seen in 42 patients. Both radiological (median size 2.6 cm, P = 0.051) and pathological (median size 3.65 cm, P = 0.015) size of tumor, tumor involving isthmus or bilateral lobes (P = 0.006), and lymphovascular invasion (LVI) (P = 0.026) had significant correlation with contralateral LNM. Conclusion: Size and site of tumor, ipsilateral lateral compartment nodes involvement, and LVI status of tumor significantly increases the probability of contralateral LNM in patients of PTC.
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The utility of the Ion Torrent PGM next generation sequencing for analysis of the most commonly mutated genes among patients with colorectal cancer in India p. 218
Simmi Mehra, Aseem Kumar Tiwari, Swati Pabbi Mehta, Ritesh Sachdev, Chhavi Rajvanshi, Rajni Chauhan, Abhishek Saini, Ashok Vaid
DOI:10.4103/ijc.IJC_723_19  PMID:33753628
Background: The requirement for the mutation analysis for Kirsten rat sarcoma viral oncogene (KRAS) in colorectal cancer (CRC) is rapidly increasing as it is a predictive biomarker and also, its absence signifies response to anti-epidermal growth factor receptor (anti-EGFR) antibody treatment. The aim of our study was to investigate the pathological diagnosis and distribution of KRAS mutations in colorectal cancer with the use of next generation sequencing platform (Ion Torrent). Methods: A total of 56 CRC samples were tested to identify the genetic mutations, especially KRAS using the primers which included ~2800 COSMIC mutations of 50 oncogenes. Ion Torrent personal genome machine (semiconductor-based sequencing) was used for the sequencing and analysis. Along with KRAS, other 49 genes were also studied for COSMIC mutations. Results: KRAS mutation 25 (44.6%) had the highest frequency, followed by TP53 10 (17.9%) and PIK3CA mutation 4 (7.1%). Of all the KRAS mutations identified, mutations in codon 12 were most frequent followed by mutations in codon 13 and 61. The most frequent substitution was glycine to aspartate mutation in codon 12 (p.Gly12Asp) followed by glycine to valine (p.Gly12Val). Combinations of mutations were also studied. Our study revealed that seven cases (12.5%) had both KRAS and TP53 mutations (highest of all the combinations). Conclusion: The analysis of KRAS mutation frequency and its mutational subtype analysis in human CRCs by using semiconductor-based platform in routine clinical practices have been performed in Indian population. The findings were similar to earlier published reports from the Western literature.
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A clinical study of serum human epididymis protein 4 (HE4) in the diagnosis of pancreatic cancer p. 223
Weiqi Liu, Weiling Liu, Keng Lin, Yuhua Liu, He Hu, Lina Yang
DOI:10.4103/ijc.IJC_752_19  PMID:34380855
Background: Pancreatic cancer (PC) has poor early diagnosis rates due to its insidious onset. Since human epididymis protein 4 (HE4) is highly expressed in patients with PC, we assessed whether serum HE4 could be a marker for the detection 3 of PC. Method: Between May 2017 and October 2018, 127 patients with PC were recruited for the study along with 108 healthy controls who underwent health examinations. Serum HE4 concentrations were determined together with levels of carcinoembryonic antigen (CEA) and carbohydrate antigens (CA) 242 (CA242), CA19-9, CA15-3, and CA72-4 by electrochemiluminescence immunoassay (ECLIA) or chemiluminescence immunoassay (CLIA). Correlations between these biomarkers were assessed. Results: Serum levels of all six biomarkers were higher in patients with PC than in controls (P < 0.05). No correlation was observed between the serum levels of HE4 and the five other tumor markers, although there were strongly significant positive correlations between CA19-9 and CA15-3, and between CA242 and CA72-4. The lack of correlation indicates that HE4 has independent value in the diagnosis of PC. The combined assessment of serum HE4 levels and the other tumor markers improved the sensitivity of diagnosis. In particular, HE4 combined with CA19-9 performed significantly better than HE4 alone, or CA19-9 combined with the other markers. The HE4/CA19-9 combination resulted in 94.49% sensitivity and 99.07% specificity (95% confidence interval: 96.9–100). Conclusion: HE4 is a biomarker associated with PC with a high specificity , either used alone, or evaluated with other biomarkers together improving the detection of PC. This study may provide a new clinical diagnostic approach for PC detection.
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Fluid-attenuated inversion recovery diffusion-weighted imaging (DWI) for evaluating chemotherapy response in patients with acute leukemia: Comparison with conventional DWI p. 230
Xue Tian, Jinliang Niu, Wenjin Li, Xiaohong Joe Zhou, Wenqi Wu, Xiaojun Li, Jun Wang, Hongwei Wang
DOI:10.4103/ijc.IJC_765_19  PMID:34380856
Background: At present, the diagnosis and efficacy evaluation of acute leukemia (AL) are assessed by bone marrow aspiration, which is invasive and subject to sampling errors. Therefore, there is a pressing need to develop a noninvasive and accurate imaging method to evaluate bone marrow changes in patients with AL. This study aimed to compare the apparent diffusion coefficient (ADC) values obtained from fluid-attenuated inversion recovery diffusion-weighted imaging (FLAIR-DWI) and conventional DWI in the lumbar bone marrow of patients with AL and to investigate their performance for evaluating response to induction chemotherapy. Methods: A total of 28 patients with newly diagnosed AL and 25 patients with AL after induction chemotherapy underwent MRI scans at 1.5 Tesla using a conventional DWI and a FLAIR-DWI sequence on sagittal planes covering the lumbar bone marrow. Further, the ADC values from these two sequences, denoted as ADCCON and ADCFLAIR, were measured on multiple vertebrae. The percentage of leukemia cells in bone marrow was recorded, and bone marrow aspiration was performed on treated patients to determine complete remission (CR) and nonremission (NR). Results: ADCFLAIR [(0.453 ± 0.103) × 10−3 mm2/s] was significantly lower than ADCCON [(0.486 ± 0.096) × 10−3 mm2/s] in the 28 untreated patients (t = 3.051, P = 0.005). In the 25 treated patients, ADCFLAIR and ADCCON values [(0.566 ± 0.239) × 10−3 mm2/s] and [(0.716 ± 0.235) × 10−3 mm2/s], respectively, were higher compared with the untreated patients. The ADCCON values showed a nonsignificant difference between the CR (n = 18) and NR (n = 7) groups (t = 1.409, P = 0.305). However, the ADCFLAIR values exhibited statistically significant difference (t = 2.542, P = 0.018) between the two groups. In a receiver operator characteristic (ROC) analysis, the area under the curve (AUC) using ADCFLAIR (0.770) was larger than that of ADCCON (0.611) in distinguishing the CR and NR patients following the chemotherapy. Conclusion: Although both ADCCON and ADCFLAIR are sensitive to tissue changes induced by chemotherapy, FLAIR-DWI outperformed conventional DWI in separating AL patients with CR from NR after chemotherapy. A possible mechanism is that FLAIR-DWI suppresses signals from free water, making the ADC measurement more sensitive to structural changes in the bone marrow.
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Extended-spectrum of KRAS and NRAS mutations in lung cancer tissue specimens obtained with bronchoscopy p. 236
Muserref Basdemirci, Adil Zamani, Ayse G Zamani, Siddika Findik, Mahmut S Yildirim
DOI:10.4103/ijc.IJC_766_19  PMID:34380837
Background: Mutations in the RAS genes, HRAS, KRAS, and NRAS, are the most common modifications in many types of human tumors and are found in approximately 30% of all human cancers. These mutations are usually found in codons 12, 13, or 61. Methods: The aim of this study is to evaluate mutations in codons 59, 117, and 146 of KRAS and NRAS genes in addition to codons 12,13, and 61 of KRAS gene in lung cancer tissue specimens obtained with bronchoscopy. KRAS and NRAS mutation analyses with pyrosequencing were performed on DNA isolated from formalin-fixed paraffin-embedded (FFPE) tissue samples of 64 patients histopathologically diagnosed as lung cancer after bronchoscopic biopsy. Results: In all, 20 patients (31.2%) had mutations in KRAS gene (8/27 squamous cell carcinoma, 8/11 adenocarcinoma, 3/16 small cell carcinoma, and 1/1 pleomorphic carcinoma). The most common mutation in codon 12 was in c.35G>T (G12V). When the mutation rate of adenocarcinoma (72.7%) and squamous cell carcinoma (22.9%) patients was compared with each other, a statistically significant difference was observed (P = 0.008). There were no mutations in codons 59, 117, or 146 of KRAS and NRAS genes in patients with lung cancer. Conclusion: In this study, we firstly examined mutations in codons 59, 117, and 146 of KRAS and NRAS genes in addition to codons 12, 13, and 61 of KRAS gene in Turkish lung cancer patients both in non-small cell lung cancer and small cell lung cancer. Although no mutation was detected in codons 59, 117, and 146 of KRAS and NRAS genes, the frequency of KRAS gene mutation was higher than the rate of mutation in both Asian and Western countries, and multicenter studies including more cases should be performed to further explore our results.
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Sequential chemotherapy after definitive radiotherapy in markedly elderly patients with advanced esophageal cancer p. 244
Shigenobu Watanabe, Ichiro Ogino, Chikara Kunisaki, Masaharu Hata
DOI:10.4103/ijc.IJC_768_19  PMID:33402604
Background: Concurrent chemoradiotherapy (CCRT) is the standard treatment for advanced esophageal cancer, but it may be more invasive in the elderly and definitive radiotherapy (RT) alone may be selected. This study assessed the significance of sequential chemoradiotherapy (SCRT) in elderly esophageal cancer patients. Methods: We reviewed 87 patients aged 75 years and older, who were treated using definitive radiotherapy without concurrent chemotherapy for esophageal cancer. A total dose ranging from 50.4 to 63 Gy (median, 58.8) was delivered to the primary lesion and the involved lymph nodes. This study compared patients who received SCRT with those who received RT alone among 40 patients with stage III or IVA cancer. Descriptive statistics were calculated using Cox proportional hazards regression analysis and the generalized Wilcoxon test. Results: The total progression-free survival (TPFS), progression-free survival outside the irradiation field, and overall survival were significantly longer after SCRT (n = 15) than after definitive RT alone (n = 25; P = 0.0041 and 0.0098), whereas the progression-free survival in the irradiation field was not significantly different between the two groups. The TPFS was significantly shorter in patients who received RT alone than in those who received SCRT (P = 0.0372). There were no grade 4 or higher adverse events in the patients who received SCRT. Conclusion: SCRT was associated with a reduced relapse rate, suggesting that it should be considered for markedly elderly patients with advanced esophageal cancer.
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Predictive role of neutropenia under crizotinib treatment in ALK-rearranged nonsmall cell lung cancer patients: A single-institution retrospective analysisPaid article p. 251
Pınar Gürsoy, Burcu Çakar, Deniz Nart, Erdem Göker
DOI:10.4103/ijc.IJC_71_20  PMID:35017371
Background: Anaplastic lymphoma kinase (ALK)-rearranged nonsmall cell lung cancer (NSCLC) represents a molecular subgroup with high sensitivity to ALK inhibitors. Tyrosine kinase inhibitor crizotinib, an anticancer drug acting as an ALK inhibitor, has shown remarkable response in ALK-positive NSCLC. The aim of our study is to explore the adverse events (AEs) of patients on crizotinib therapy and analyze the predictability of AEs for better survival or response on NSCLC patients. Methods: The medical records of our ALK-positive metastatic NSCLC patients who applied between years 2013 and 2018 had been reviewed retrospectively. ALK positivity of all patients had been detected by fluorescence in situ hybridization and no other driver mutations were present. Patient demographics, performance status, smoking history, previous treatments, metastatic sites, and AEs were recorded for further analyses. Results: Thirty-six ALK-positive metastatic NSCLC patients were included in the study. Median follow-up was 30.1 months. Median progression-free survival (PFS) for patients who developed hepatic, cardiac, or endocrine toxicities was similar when compared to patients who did not develop. Although there was a numeric median PFS difference between patients who did develop visual disorders (18.4 months) and did not develop visual disorders (15.5 month), this was not regarded as statistically significant. However, median PFS of the patients who developed neutropenia upon crizotinib treatment (31.9 months) was found to be more favorable than the patients with normal neutrophil counts (12.8 months) (P = 0.026). Conclusion: Neutropenia under crizotinib treatment was found to be associated with improved PFS suggesting that neutropenia might be an important determinant in treatment and survival strategies.
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Oligometastatic breast cancer: An institutional analysis p. 257
Ajay Gogia, Surya V S Deo, Daya N Sharma, Sandeep Mathur
DOI:10.4103/ijc.IJC_169_20  PMID:35946184
Introduction: Oligometastatic represents a distinctive subset of metastatic breast cancer (MBC). Incidence has been reported, in 1–5% of all newly diagnosed MBC. Literature is very sparse, especially from India. Material and Methods: We have ambispectively screened 500 patients of upfront female MBC between the period of January 2013 and August 2018 at Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi and 120 patients of oligometastatic breast cancer (OMBC) were included for analysis. Clinical, pathological, receptor status (ER estrogen receptor, PR progesterone receptor, and HER2/neu human epidermal growth factor), radiological, treatment, and survival details were recorded. Results: The median age of presentation was 50 (range 22–78) years. One organ was involved in 96 (80%) patients, and two organs were involved in 36 (20%) patients. ER and/or PR was positive in 48 (40.0%), ER/PR, and HER2/neu were positive in 28 (23.3%) cases. Only HER2/neu was positive in 21 (17.5%), and triple negativity was seen in 23 (19.2%) patients. Ninety-four (78.3%) patients received neoadjuvant therapy, and 12 (10%) patients underwent conservative breast surgery. The overall response rate at the metastatic site was 74.1%, and a complete response was seen in 42.5% of patients. Median progression-free survival (PFS) for the cohort was 25.43 months. The estimated PFS at 2 years and, at 5 years, was 54.6% and 21.6%, respectively. The hormone receptor positivity, bone metastasis, and patients with surgery after neoadjuvant chemotherapy (NACT) had a statistically significant better PFS on multivariate analysis. In a subset analysis of HER2/neu receptor-positive patients, who received targeted therapy showed better PFS compared to those who did not receive. Conclusion: The incidence of OMBC is 24% of the total MBC. The patients with OMBC who have hormone receptor-positive, bone-only metastasis, and surgery after NACT show a better outcome.
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MCQS Top

MCQs on “Sequential chemotherapy after definitive radiotherapy in markedly elderly patients with advanced esophageal cancer” p. 263
HS Darling, Pradeep Jaiswal, Nishant R Tiwari
DOI:10.4103/ijc.ijc_725_22  PMID:35946185
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CASE REPORTS Top

Refractory cancer pain in young child at end-of-life: Can we alleviate the suffering? p. 265
Shilpi Agarwal, Vikram Pratap Singh, Akansha Sangwan, Seema Mishra
DOI:10.4103/ijc.IJC_635_20  PMID:35946186
Pain is a common and highly distressing symptom in children with advanced malignancies and it is often multifactorial at the end-of-life. The prognosis of cancer pain is reported to be worse in those with mixed pain type, high pain severity, daily opioid use, and poor emotional well-being. We describe a case of 13-year-old boy, known case of metastatic Ewing sarcoma right iliac bone, who presented to our palliative care ward with intractable pain and was finally discharged home for terminal care with high doses of morphine, ketamine, and midazolam infusion through elastomeric pump attached to a peripherally inserted central catheter (PICC line). The suffering of imminently dying children should be reduced, and judicious dose escalation of opioids along with adjuvants is appropriate and often necessary.
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Successful treatment of a patient with recurrent metastatic clear cell carcinoma of the uterine cervix p. 269
Su Jung Shim, Nae Yoo Kim, Ho Jung Lee, Soo Jung Gong
DOI:10.4103/ijc.IJC_821_20  PMID:35946187
Clear cell carcinoma (CCC) of the uterine cervix is a rare gynecologic cancer that accounts for 4–9% of adenocarcinoma of the uterine cervix. Two types of uterine cervical CCCs are known: A type that is associated with in utero exposure to diethylstilbestrol (DES) and idiopathic type that is unrelated to DES exposure. Due to its rare incidence, the clinical behavior and pathological characteristics of CCCs are not fully described and treatment recommendations are not standardized. Moreover, only a few cases are reported on the recurrent metastatic CCCs and the results of various treatment trials are inconsistent. We present a case of successfully treated idiopathic metastatic CCC of the uterine cervix that recurred after concurrent chemoradiotherapy.
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Cotard's syndrome in the postoperative period following head and neck cancer surgery – A case report p. 273
Nitish Thakur, Mahima Gupta, Raghav Gupta, Seema Mishra
DOI:10.4103/ijc.IJC_825_20  PMID:35946188
Major head and neck surgery is a known factor for postoperative delirium; however, Cotard's syndrome (CS) has been rarely reported following head and neck surgery. We report a case of a 51-year-old man who underwent surgery for carcinoma right buccal mucosa and developed agitation and nihilistic delusion after extubation. The patient had a preexisting psychiatric history which is often reported as a risk factor for CS. Of interest, though is that this condition subsided as quickly as it emerged with only supportive counselling and brief pharmacotherapy.
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Relapse of pemphigus foliaceus initiating at the site of irradiation in an elderly male with laryngeal carcinoma: Illustrating the concept of immunocompromised cutaneous district p. 276
Namrata Chhabra, Saurabh Raut, Satyaki Ganguly, Nighat Hussain
DOI:10.4103/ijc.IJC_853_20  PMID:35946189
Radiotherapy-induced or -aggravated pemphigus is not a common occurrence with only a few cases reported so far. The radiation disrupts the local immune regulation and alters the antigenicity of keratinocytes, but the exact etiology is not clear. We report a case of an elderly man operated for laryngeal carcinoma who presented with recurrence of pemphigus foliaceus lesions starting at the irradiation site. The appearance of vesiculobullous lesions at the site of irradiation should be evaluated thoroughly to rule out immunobullous diseases.
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Expression of mismatch repair proteins in urothelial carcinoma of the urinary bladder p. 279
Rasheeda Mohamedali, Amit K Adhya, Swarnendu Mandal, Suvradeep Mitra
DOI:10.4103/ijc.IJC_225_21  PMID:35946190
Background: Urothelial carcinoma of the urinary bladder (UCUB) is a frequently diagnosed malignancy. Mismatch repair (MMR), a proofreading machinery of the DNA, prevents tumorigenesis. The role of MMR deficiency in UCUB in eastern Indian population is not known. Methods: Immunohistochemistry panel for MLH1, PMS2, MSH2, and MSH6 (MMR proteins) was performed on the biopsy specimens of UCUB (N=100). Results: MMR deficiency by immunohistochemistry was demonstrated in two cases (2%). One case showed deficiency of MSH2 and MSH6 and the other case showed the deficiency of all four mismatch proteins. Both cases showed high-grade invasive urothelial carcinoma by histomorphology. Conclusion: The prevalence of MMR deficiency by immunohistochemistry is 2% in eastern Indian population.
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PERSPECTIVE Top

Looking beyond the obvious: Role of non-invasive electroanalgesia in management of cancer pain p. 282
Ridhi Verma, Manu Shivadeva, Divya Priya Bhupal, Sundar Kumar Veluswamy
DOI:10.4103/ijc.IJC_1340_20  PMID:35946191
Pain is considered as one of the most debilitating symptoms of cancer and its treatment. Owing to the limited efficacy of traditional pharmacological interventions to address cancer pain in its entirety, an avenue exists for exploration into nonpharmacological therapies. Analgesia using non-invasive electrotherapeutic modalities such as transcutaneous electrical nerve stimulation (TENS) and scrambler therapy emerges as a viable option to address cancer pain. The inability of these modalities to find a place within the recommended clinical guidelines has possibly resulted in the paucity of application of the same within the clinical setup. This perspective article aims at stimulating a discussion surrounding the inclusion of non-invasive neuromodulatory treatment techniques such as TENS and scrambler therapy to combat cancer pain and explore the benefits and pitfalls of using these techniques as an adjunct to the pre-existing treatment strategies. It is envisioned that this opinion piece will open a dialogue about a possible home for non-invasive electroanalgesia within the clinical treatment pathway for cancer pain.
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VIEW POINT Top

Anticancer properties of melatonin and its role as an adjuvant in cancer treatment p. 288
Abhijit Nair
DOI:10.4103/ijc.IJC_1197_20  PMID:35946192
Melatonin is an important hormone secreted from the pineal gland that mediates several biological functions in humans through circadian rhythm. The multimodal properties of melatonin when administered systemically have generated a lot of interest among researchers. The anticancer properties of melatonin per se and its importance in cancer patients when used as an adjunct to ongoing chemotherapy and radiotherapy have led to tremendous research in animals and humans with encouraging results. The present write-up discusses the current evidence of using melatonin as an adjunct in hormone-dependent and hormone-independent cancers.
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IMAGES IN ONCOLOGY Top

Rare chemotherapy-related tracheoesophageal fistula secondary to lymphoma p. 295
Ang Qi Xuan, Sakina Ghauth, Liew Yew Toong
DOI:10.4103/ijc.IJC_1350_20  PMID:35946193
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LETTERS TO THE EDITOR Top

Oncocytic variant of adrenocortical carcinoma: A rare entity p. 297
Siddhi G Sinai Khandeparkar, Maithili M Kulkarni, Smita G Solanke, Prajakta A Shinde
DOI:10.4103/ijc.IJC_278_21  PMID:35946194
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Collateral damage to elderly patients presenting with advanced skin cancer. Another toll to pay due to COVID-19 pandemic p. 300
Luigi M Lapalorcia, Puya D Mobaraki, Giuseppe Guarro, Romano Maffia, Valerio Finocchi, Marino Cordellini
DOI:10.4103/ijc.IJC_189_21  PMID:35946195
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Initial experience with the development of a lung cancer tumor board in a tertiary cancer center p. 302
Leo Sneha, Rajaram Manju, Penumadu Prasanth, Ganesan Prasanth
DOI:10.4103/ijc.IJC_220_21  PMID:35946196
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NEWS Top

News from the world of oncology p. 304

DOI:10.4103/ijc.ijc_750_22  
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