Artificial intelligence (AI) has found its way into every sphere of human life including the field of medicine. Detection of cancer might be AI's most altruistic and convoluted challenge to date in the field of medicine. Embedding AI into various aspects of cancer diagnostics would be of immense use in dealing with the tedious, repetitive, time-consuming job of lesion detection, remove opportunities for human error, and cut costs and time. This would be of great value in cancer screening programs. By using AI algorithms, data from digital images from radiology and pathology that are imperceptible to the human eye can be identified (radiomics and pathomics). Correlating radiomics and pathomics with clinico-demographic-therapy-morbidity-mortality profiles will lead to a greater understanding of cancers. Specific imaging phenotypes have been found to be associated with specific gene-determined molecular pathways involved in cancer pathogenesis (radiogenomics). All these developments would not only help to personalize oncologic practice but also lead to the development of new imaging biomarkers. AI algorithms in oncoimaging and oncopathology will broadly have the following uses: cancer screening (detection of lesions), characterization and grading of tumors, and clinical decision-making and prognostication. However, AI cannot be a foolproof panacea nor can it supplant the role of humans. It can however be a powerful and useful complement to human insights and deeper understanding. Multiple issues like standardization, validity, ethics, privacy, finances, legal liability, training, accreditation, etc., need to be overcome before the vast potential of AI in diagnostic oncology can be fully harnessed.

Renal tumors comprise a wide spectrum of benign and malignant tumors. The important prognostic factors in renal cell carcinoma include pathological stage, tumor grade, morphological type, sarcomatoid/rhabdoid differentiation, and tumor necrosis. Therefore, the pathologist needs to be fully aware of how to gross nephrectomy specimens to be able to accurately provide the above prognostic information while reporting adult kidney tumors. With the advent of nephron-sparing surgeries, due diligence should be exercised to assess and sample the parenchymal surgical margin. This article discusses the approach to grossing nephrectomy specimens, elaborates the significance of every step, and also sheds light on the importance of clinical and radiological information in providing a holistic approach to the diagnosis and staging of adult renal tumors.

Background: Hemato-oncologic patients on chemotherapy or undergoing bone marrow transplantation are susceptible to infections due to neutropenia. Incidences of febrile neutropenia (FN) in these patients are common, contributing to high mortality and morbidity. Lack of diagnosis of pathogens responsible for infections in these patients is a major healthcare challenge. Newer molecular diagnostics are increasingly becoming relevant. The objective of this retrospective study was to evaluate the effectiveness of Syndrome Evaluation System (SES), a multiplex molecular diagnostic platform for diagnosis of pathogens, and its impact on the management of FN. Methods: In total, 34 neutropenic episodes from 21 patients admitted during September 2013 to April 2015 were analyzed in this study. Clinical samples from patients were tested on SES and routine culture. Treatment was as per standard of care. Results: SES showed a 5-fold higher clinical sensitivity (55.9%) as compared to automated culture (11.1%). SES results were available within 14 hours as compared to >72 hours for culture, and elucidated change in antimicrobial therapy in 50% of episodes. Mortality rates were lower when SES was used early in the episode. De-escalation of antimicrobials according to SES results was possible, which translated into substantial cost saving. Conclusion: Newer non–culture-based molecular technologies like SES are changing the way we manage FN. It is faster, has a higher diagnostic yield as compared to traditional culture, and helps in making rapid, evidence-based therapeutic decision-making including de-escalation of antimicrobials. It would potentially lead to a reduction in mortality and healthcare cost in the long run.

Background: Pancreatic exocrine insufficiency (PEI) is a well-defined complication of malignant diseases and pancreatic resection; however, study results of PEI are less consistent. Assessment of PEI by estimation of fecal elastase (FE)-1 in stool by enzyme-linked immunosorbent essay (ELISA) is a relatively inexpensive, noninvasive, and simple test. This study assessed exocrine function of pancreas following pancreaticoduodenectomy (PD) by estimating FE-1. Methods: This prospective hospital-based study involved 30 patients who had undergone PD for malignancy. All 30 patients had an uneventful postoperative period under the unit's enhanced recovery after surgery (ERAS) protocol with no Grade B, C postoperative pancreatic fistula/postpancreatectomy hemorrhage as per the International Study Group of Pancreatic Surgery (ISGPS) definitions. Stool samples were collected postoperatively 3 months after surgery from all patients irrespective of clinical symptoms. The analysis was based on a solid phase ELISA used for the quantitative determination of human elastase 1 in feces. Fecal elastase was considered normal if >200 μg/gm stool, moderately reduced if 100–200 μg/gm stool, and severely reduced if <100 μg/gm stool. Results: Among 30 patients included, fecal elastase levels were moderately reduced in 10 (33.33%) and severely reduced in 20 (66.67%) patients (P <0.0001). Mean (± standard deviation) of fecal elastase was 87.12 ± 38.76 with median of 74.6 μg/gm stool. There was no significant difference in the fecal elastase levels between men and women (P = 0.057), age (P = 0.48), pancreatic duct diameter (P = 0.609), pancreatic texture (P = 0.286), and presence or absence of clinical symptoms (P = 0.181). Conclusions: PD was frequently associated with PEI. Unfortunately PEI is an under recognized and under treated long-term sequel of PD. Fecal elastase 1 should be performed routinely in both symptomatic and asymptomatic patients. Pancreatic enzyme replacement therapy should be considered in every patient after PD.

Background: The effect of high-dose-rate (HDR) brachytherapy after external radiation in high-risk prostate cancer patients has been proven. Stereotactic body radiotherapy as a less invasive method has similar dosimetric results with HDR brachytherapy. This study aims to evaluate the prostate-specific antigen (PSA) response, acute side effects, and quality of life of patients who underwent stereotactic body radiotherapy (SBRT) as a boost after pelvic radiotherapy (RT). Methods: A total of 34 patients diagnosed with high-risk prostate cancer treated with SBRT boost (21 Gy in three fractions) combined with whole pelvic RT (50 Gy in 25 fractions) were evaluated. Biochemical control has been evaluated with PSA before, and after treatment, acute adverse events were evaluated with radiation therapy oncology group (RTOG) grading scale and quality of life with the Expanded Prostate Cancer Index Composite (EPIC) scoring system. Results: The mean follow-up of 34 patients was 41.2 months (range 7-52). The mean initial PSA level was 22.4 ng/mL. None of the patients had experienced a biochemical or clinical relapse of the disease. Grade 2 and higher acute gastrointestinal (GI) was observed in 14%, and genitourinary (GU) toxicity was observed in 29%. None of the patients had grade 3-4 late toxicity. Conclusions: SBRT boost treatment after pelvic irradiation has been used with a good biochemical control and acceptable toxicity in high-risk prostate cancer patients. More extensive randomized trial results are needed on the subject.

Background: The association of sex hormones with receptor status and breast cancer (BC) incidence is studied with inconclusive results. The present work assessed the serum estrogen, progesterone, and testosterone concentrations and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status of newly diagnosed Sri Lankan BC patients and studied the possibility of risk assessment for BC using these parameters. Methods: Serum estrogen, progesterone, and testosterone concentrations of newly diagnosed BC patients (n = 155) were assessed and compared with apparently healthy age-matched women (n = 75). Hormone concentrations were assessed with an enzyme immunoassay competition method with fluorescent detection (Biomerieux, France). Hormone receptor statuses were recorded from histopathology reports. Results: Estrogen and progesterone concentrations were not significantly different according to the menstrual phase of premenopausal BC or healthy women or according to the menopausal status. Testosterone concentration of BC patients was significantly (P = 0.001) lower than in apparently healthy women. Estrogen and progesterone concentrations were not significantly different according to ER and PR status. However, progesterone concentrations of postmenopausal were significantly different (P = 0.021) among HER2 overexpressed women when compared to HER2-negative women. Postmenopausal women with progesterone level below 0.25 ng/mL were more likely to have HER2 overexpressed (P = 0.002). Conclusions: Serum estrogen and progesterone concentrations of BC patients were not significantly different when compared with apparently healthy women. Women with testosterone level below 0.26 ng/mL demonstrated a higher risk of having BC. Serum progesterone concentrations of BC patients were significantly higher among HER2 overexpressed women compared to HER2-negative women.

Background: Stereotactic body radiotherapy (SBRT) is increasingly being performed for hepatocellular cancer and liver metastases. The purpose of this study was to review the practice of SBRT for hepatocellular, pancreatic cancer and liver metastases in India. Methods: A survey comprising of 25 questions was designed and served to radiation oncology professionals at two major conferences. The survey consisted of 25 multiple choice questions on SBRT infrastructure and caseload, simulation methods and immobilizations, organ motion control methods, simulation and delivery, indications of liver and pancreatic SBRT and prescribed dose. The responses were analyzed using descriptive statistics. Results: From January to June 2017, about 200 professionals were approached and 71 professionals responded with a response rate of 35.5%. The duration of the SBRT practice among respondents was less than 3 years in 53% with 32% having formal training in SBRT. The most common sites for the use of SBRT were lung and brain followed by liver and spine. Liver SBRT was practiced by 29 (59.2%) for hepatic oligometastases, hepatocellular carcinoma (HCC), and cholangiocarcinoma. The most common fractionation used was 50–60 Gy/6 fractions and 45 Gy/3 fractions. Pancreatic SBRT was practiced by 37%, mostly for medically inoperable or locally advanced pancreatic cancer. SBRT was not practiced by 22 (31%) of the respondents, and the main reasons were lack of infrastructure and structured training. Conclusion: The SBRT for liver has increased with a usage rate of over 50% amongst respondents. Pancreatic SBRT use is infrequent and limited to inoperable or advanced cases. Lack of infrastructure and training are the main challenges in the routine adaptation of SBRT.

Background: In this real-life practice study, we aimed to find whether elderly colorectal cancer (CRC) patients in our center were treated optimally and also if this has an effect on overall survival (OS) or not. Methods: We have retrospectively screened 150 CRC patients older than 65 years, diagnosed in our institution between 2010 and 2018. As study variables, patient characteristics, tumor location, tumor, nodes, metastases stage, Eastern Cooperative Oncology Group performance status (ECOG PS), comorbidities, adjuvant or metastatic chemotherapy regimens, and treatment toxicity were recorded, and the OS rate of patients was assessed. Results: The median age was 72 (range 65 - 89) years and 48 (32%) patients had metastatic disease at the time of diagnosis. The median OS (mOS) in the suboptimal adjuvant treatment group was 31.5 (range 20.7–42.3) months, whereas mOS was not reached during the median follow-up time in the optimal treatment group (P = 0.036). The addition of oxaliplatin to chemotherapy had no benefit on mOS (P = 0.318). In the metastatic setting, the mOS in the optimal and suboptimal treatment group was 27.2 (range 10.7-43.7) months and 13.4 (range 7.5-18.8) months respectively, and was statistically significant (P = 0.001). Conclusion: Our study revealed that optimal treatment had a significant effect on the mOS of elderly CRC patients and it was well tolerated. Advanced age alone is not a sufficient parameter for precluding effective therapy in elderly patients with CRC.

Background: Acute neurological complications occur in 3.6-11% of children treated for acute lymphoblastic leukemia (ALL). This analysis aimed to evaluate the profile of acute neuro-toxicity and its etiology in children with ALL. Methods: A retrospective case analysis of central nervous system events in children treated for ALL at our center was performed. Details of events were retrieved from the case records (January 2006-December 2015) and analyzed. Results: Ninety (9.5%) neurological events occurred in 923 patients treated for ALL. Phase of therapy were: induction (38), consolidation (5), interim maintenance (5), intensification (15) and maintenance (27). Seizures and neurological deficits were the presenting features in 64 and 40 children, respectively. Events included : neuro-infections in 18, posterior reversible encephalopathy syndrome (PRES) in 7, epilepsy in 6, intracranial bleed in 5, systemic infection with neurological complication in 4, hydrocephalus and aseptic meningitis in 3 each, methotrexate encephalopathy and metabolic seizures in 2 children each. Seizures and status epilepticus of unknown etiology and neurological deficits of unknown etiology was observed in 26 and 13 children, respectively. Seizures occurred mainly in induction (12) and intensification phase (9). Status epilepticus transpired in maintenance phase in 9/14 patients. Induction phase was complicated by PRES in 7, intracranial bleed in 5 and cerebral sinus venous thrombosis in 1 patient. Neuroimaging was done in 86% of events. There were 18 (20.6%) deaths: neuro-infections (8), status epilepticus (6), systemic infection (2), bleed (1), and unexplained encephalopathy (demyelination)(1). At last follow-up, 53 patients were well and 7 children persist to have a neurological disability. Conclusion: Ten percent of children on treatment for ALL suffered an acute neuro-toxicity. Morbidity and high-incidence of neuroinfections are major concerns.

Background: Despite all advanced treatment methods for rectal cancer, not all patients can provide an adequate response, and hence, possible prognostic factors must be evaluated. The aim of this study was to evaluate the relationship between systemic inflammatory markers and pathological response, overall survival (OS) and disease-free survival (DFS) in patients treated with neoadjuvant chemoradiotherapy (nCRT). Methods: We evaluated data of 117 patients for the period 2010 to 2017. Serum measurements of albumin, hemoglobin, C-reactive protein, modified Glasgow prognostic score (mGPS), and white cell counts were obtained. Rodel scoring system was used to determine pathologic tumor regression. Results: Overall, 77% of the patients were in the good response group according to the radiological images. A total of 48% of patients were categorized as a good pathologic response. Pathologic response to treatment was associated with a mGPS of 0 (P = 0.001), normal platelet lymphocyte ratio (PLR) (P = 0.003), TNM stage (P = 0.03), pathologic T stage (P = 0.001), radiologic response to nCRT (P = 0.04), tumor differentiation (P = 0.001), lymphovascular invasion (LVI) (P = 0.001) and perineural invasion (P = 0.02). LVI (P = 0.04), albumin level (P = 0.05), C-reactive protein (P = 0.01), neutrophil platelet score (NPS) (P = <0.001) and mGPS (P = 0.01) had a statistically significant effect on OS. Operation type (P = 0.03), tumor differentiation (P = 0.01), depth of invasion (P = 0.03), NPS (P < 0.01), mGPS (P = 0.01), PLR (P = 0.004), neutrophil-lymphocyte ratio (P = 0.01) and LVI (P = 0.05) were statistically significant on DFS. Conclusions: There was an association between systemic inflammatory markers and pathologic response and also, between OS and DFS. This study can be preliminary data for prospective controlled studies.

Background: Programmed death-ligand 1 (PD-L1) has been determined as a reliable prognostic factor for various malignancies. In this study, we aimed to determine the prognostic effect of PD-L1 expression in tumor-infiltrating immune cells (TIICs) of nasopharyngeal carcinoma (NPC) patients. Methods: Seventy patients diagnosed with non-metastatic NPC were included in the study. PD-L1 expression on immune cells was analyzed by immunohistochemical method. Patients were categorized into two groups according to the PD-L1 expression level in TIICs (level of PD-L1 staining ≥5% positive vs <5% negative). Results: Median follow-up period was 34 months (range = 1 - 188). 1 and 2 years survival rate were found as 75% and 63% in PD-L1 negative TIICs group (47%), and 85% and 83% in PD-L1 positive TIICs group (53%), respectively. PD-L1 positivity in immune cells (ICs) was detected in 53% of the patients. The survival rate was found better in the PD- L1 positive group compared to the negative group (P = 0.049). Discussion: In conclusion, the survival rate was found significantly better in the PD-L1 positive TIICs group, compared to the negative group.

Background: Oral cancer is one of the leading causes of mortality in the world over and is a major public health problem. There are numerous resources on the internet which provide information related to oral cancer. However, they may not be optimal and standardized. The present study was conducted to assess the quality, readability, and content of the online resources for oral cancer. Methods: The content analysis approach was employed for the present study. Google search engine was employed to search for various online resources on oral cancer. The first 50 websites were evaluated for their quality and readability. Flesch–Kincaid readability tests were used to assess the readability of the internet material and consisted of Flesch reading ease and Flesch–Kincaid grade level. The quality of websites was assessed by Journal of American Medical Association (JAMA) benchmarks and HONcode (Health Over Net code). Results: A total of 12 (32.43%) of the websites were fairly difficult to comprehend, while none of the websites were easy/very easy to comprehend. A total of 8 (21.62%) websites were readable by only college-level graduates. Overall, 21 (56.76%) of the websites did not have HONcode certification. Conclusion: The present study revealed that a majority of the websites were fairly difficult to comprehend and readable by college-level graduates. There is a definite need to monitor the quality of the websites on oral cancer. The present study highlights the need for stringent norms and regulations regarding oral cancer made available to the common man on the internet.

Background: Patient satisfaction has emerged as a yardstick to measure success of healthcare ecosystems. OUTPATSAT-35RT is a questionnaire to assess patient satisfaction on outpatient radiotherapy (RT). However, it is yet to be translated and/or validated in any of the common Indian languages. Methods: English version of OUTPATSAT-35RT was pilot tested in 20 patients with working knowledge of English undergoing fractionated radiotherapy. Subsequently, the questionnaire was translated into two Indian vernacular languages (Hindi and Marathi) using standardized methodology. The process included forward translation into vernacular language by two professional translators independently, generating an intermediate version of the questionnaire. The intermediate questionnaire was then back-translated into English by another duo of professional translators and compared with the English version of the original OUTPATSAT-35RT questionnaire for final reconciliation. This was subsequently administered to 20 patients each (fluent in respective vernacular language) for pilot testing. All 60 patients (20 per language) underwent semi-structured interviews for reporting any difficulty encountered during filling and suggesting any corrections/modifications to the questionnaire. Results: The pilot testing of the English version of OUTPATSAT-35RT in 20 Indian patients did not reveal any difficulty or suggest corrections/modifications, leading to its successful translation into Hindi and Marathi languages. Pilot testing of the translated questionnaires in 20 patients each (fluent in the respective vernacular language) did not find any major difficulty. No corrections/modifications were suggested by the respondents resulting in adoption of the reconciled vernacular questionnaires as final Hindi and Marathi versions of OUTPATSAT-35RT questionnaire. Conclusion: The English version of OUTPATSAT-35RT has been successfully translated into Hindi and Marathi languages using standardized methodology. Its psychometric properties are being tested for validation in a larger Indian cohort.

Background: It is challenging to identify robust elderly patients suitable for systemic chemotherapy. The goal of this study was to ascertain clinical characteristics that may best predict the most benefit of systemic chemotherapy for geriatric patients (aged ≥80 years) with advanced solid tumors. Methods: A retrospective cohort study was conducted of advanced solid tumors patients treated with systemic chemotherapy. We divided the patients into chemotherapy tolerant and intolerant groups. We assessed the efficacy, adverse reactions, progression-free survival, and overall survival of patients treated with chemotherapy. We accounted for comorbidities, Eastern Cooperative Oncology Group performance status (PS), activities of daily living (ADL), and routine serologic lab metrics. We compiled survival curves for the two groups, and Cox regression univariate and multivariate analyses were used to identify factors that influenced survival. Results: We included 84 patients in the analyses. Comorbidities ≤3, medications ≤4, ADL score ≥90, and PS score ≤1 were associated with chemotherapy tolerance (P < 0.05). Normal D-Dimer and serum albumin concentrations were associated with chemotherapy tolerance (P < 0.05). The median overall survival was 15.0 months (95% confidence interval [CI]: 12.8 - 17.2) in the tolerant group and 7.0 months (95% CI: 4.3 - 9.7) in the intolerant group (P < 0.05). Thus, most tolerant patients (79.6%) benefited from chemotherapy. PS, ADL, normal albumin, and chemotherapy tolerance were statistically correlated with overall survival (P < 0.05). Conclusion: Some clinical characteristics were associated with chemotherapy tolerance. The overall survival time of elderly patients with good tolerance to chemotherapy was longer.

We report a case of anaplastic lymphoma kinase-positive anaplastic large T-cell lymphoma (ALK+ALCL) presenting primarily as a sinonasal mass with pseudoproptosis in an 11-year-old boy. The diagnosis was based on histopathological and immunohistochemical (IHC) evaluation, which is indispensable for determining tumor type. On the basis of clinicoradiological findings, provisional differential diagnoses of angiofibroma and rhabdomyosarcoma were made. Upon histopathological examination of the biopsy sent, the diagnosis of lymphoma in the sinonasal region was considered. Upon IHC, the tumor cells showed immunoreactivity for vimentin, CD45, CD30, and ALK. The tumor cells showed focal immunoreactivity for CD3 and CD68. Ki-67 labeling index was 70%. They were nonimmunoreactive for PAN cytokeratin, epithelial membrane antigen, cluster of differentiation (CD) 20, CD15, CD56, S100, smooth muscle actin, and myogenin. The diagnosis of ALK+ALCL was rendered. The studied IHC markers confirmed the histopathological diagnosis and helped in further subtyping. To the best of our knowledge, this is the first case of ALCL presenting primarily as a sinonasal mass with pseudoproptosis.

Triple-negative breast cancers (TNBC) are one of the most aggressive forms of breast cancers. With poor patient outcomes, it presents a great burden on the healthcare systems. There have been some efforts to explore the genomic changes that occur in TNBCs. However, there is not enough data on Indian TNBCs. We sought to understand the mutational landscape of key cancer-associated genes in Indian TNBC patients using TruSeq Cancer Amplicon Panel. We sequenced 51 TNBC patient samples and found great heterogeneity amongst samples with respect to the genomic variants. Several previously reported including alterations in PI3K-AKT pathway genes were also identified. Likewise, we identified several novel high-frequency variants, for example, GNAQ F341S (17%), the functional role of which remains unclear. Our study lays the foundation of larger efforts needed to understand the genomic landscape of Indian TNBCs which can aid in classification and better therapeutic management of patients.

Necrotizing fasciitis (NF), which is a rare but life-threatening soft tissue infection, can present as a complication of colorectal diseases. The development of NF of the lower extremity secondary to a perforated colorectal tumor has been reported in only a few patients. We present a case of a 68-year-old woman, in which necrotizing soft tissue infection of the left lower extremity was the presenting feature of a perforated rectosigmoid tumor. On examination, there was a tender swelling and edema with palpable crepitus in the left inguinal region and thigh. Computed tomography showed gas within the retroperitoneal tissues, with subcutaneous edema and emphysema extending from the thigh to the ankle. NF was diagnosed, and the patient underwent Hartmann's procedure and fasciotomy with an aggressive debridement of the left thigh and inguinal region. In the case of NF of the lower extremity or abdominal wall without an obvious cutaneous source, an intraabdominal cause should be considered and sought.

Acquired cystic disease-associated renal cell carcinoma (ACD-RCC) is the major RCC subtype in patients with end-stage renal disease, specifically those with ACD on dialysis. Three patients with a total of eight tumors have been selected. The aim of this study was to analyze clinicopathologic, immunohistochemical, and prognostic features of eight ACD-RCCs. Three patients with end-stage renal disease (ESRD) were in the age range of 34–45 years and being treated with hemodialysis. All eight tumors were resected by radical nephrectomy. Two patients had a single ACD-RCC, while one patient had bilateral and multifocal ACD-RCCs. Microscopically, combinations of architectural patterns were identified in all tumors. Intracytoplasmic and intraluminal vacuoles, eosinophilic granular cytoplasm, and prominent nucleoli were universal characteristics of these tumors. Atypical cysts were present in three out of four resected kidneys. Immunohistochemistry (IHC) staining revealed all tumors were strongly and diffusely positive for pan-cytokeratin and α-methylacyl-CoA racemase and variably positive for CK7, CD10, PAX8, EMA, vimentin, cytokeratin, high molecular weight cytokeratin (CK HMW). All cases were negative for Napsin A, CK20, CD117, and CD57. After an average follow-up of 27.5 months (range 3–54 months), all our patients are alive without neoplastic (metastatic or recurrent) disease. Our study supports the finding that ACD-RCC has specific morphologic features and a broad spectrum of architectural patterns. We have found that the immunoprofile of ACD-RCC is distinct from that in other RCCs; however, nonspecific and interpretation of microscopic features in the context of the clinical history can aid the diagnosis. We confirm also the favorable prognosis in ACD-RCC.

Narrative medicine (NM) is a new discipline in healthcare that helps the patients and physicians to tell and listen to the accounts of disease, illness, and suffering. In the last 20 years, NM has moved into the realms of biomedical education, research, and training. The complexity of cancer management can gain from the medical humanism of NM. A new model of cancer care called narrative oncology (NO) with NM-based skill sets of attention, representation, and affiliation can build narrative competence, therapeutic relationship, and clinical trust. The oncologists, patients, and their family caregivers, and the cancer care health system will create an inclusive and empathetic eco-system. This paper outlines the broad framework of NM, which becomes narrative oncology for cancer medicine. The clinicians, nurses, health workers, and scientists should learn and implement this new discipline alongside their biomedical activities.