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   Table of Contents - Current issue
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September-December 2020
Volume 4 | Issue 3
Page Nos. 79-148

Online since Thursday, November 26, 2020

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REVIEW ARTICLE  

Surrogate molecular classification of breast carcinoma: A classification in need or a dilemma indeed Highly accessed article p. 79
Khushboo Dewan, Ashish K Mandal
DOI:10.4103/oji.oji_46_19  
The biological heterogeneity of breast cancer accounts for variations in natural course of disease and differences in response to various therapeutic modalities. These variations pose as major challenges in clinical management of patient. The quest for markers that would accurately define prognosis and response to particular therapeutic modality has led us to the molecular makeup of these tumors. The technique of gene expression profiling has been pivotal in this regard. With the study of thousands of genes simultaneously in breast cancer patients, a molecular classification of breast carcinoma was proposed in the early 21st century. High-throughput commercial assays proved to be useful in predicting prognosis for the patients but are expensive. Classification of breast cancers using immunohistochemistry that can be used as a surrogate of this molecular classification is inexpensive, easier, and more convenient to use. However, the accuracy of this classification is closely dependent on accurate immunohistochemical measurement of estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and Ki67. The initial surrogate classification has undergone revisions to make it more relevant in the 13th St Gallen International Breast Conference. Newer molecular subtypes such as claudin low have also been identified but are included in the basal-like subtype in surrogate classification due to its triple-negative nature. The utility of the surrogate classification in the Indian setting is immense due to limited access to molecular techniques. This review covers in detail the evolution, prognostic, and therapeutic implications of the surrogate molecular classification of breast cancers.
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ORIGINAL ARTICLES Top

Robotic esophageal mobilization: A new norm in the future? p. 87
Rohan Shetty, K C Jalaluddin Akbar, H T Amar Rao, Manavallan Vijayakumar, R J Dinesh Reddy
DOI:10.4103/oji.oji_33_20  
Background: Esophageal cancer is one of the common cancer with high mortality. Radical resections offer the best survival. However, traditional radical resection involves thoracotomy, resulting in pulmonary complications. Video-assisted thoracoscopic surgery has overcome this but requires a long learning curve and limitations in certain areas. Robotic-assisted thoracic mobilization has shown promising results. Here, we are sharing initial experience of robotic esophageal mobilization. Aim: The aim of the study is to assess the feasibility, safety, and learning curve of performing robotic esophageal mobilization among patients with esophageal cancers. Materials and Methods: Retrospective review of medical records was conducted for 33 cases who underwent robotic esophageal mobilization in our institute from August 2016 to August 2019. Results: The study population comprised 24 men and 9 women. The mean age of presentation was 55.3 years. Mean operative time was 204 min, and mean thoracic mobilization time was 108 min. The mean lymph node retrieval was 16.6. The postoperative surgical complications were less such as pulmonary complication, i.e., pneumonia in three patients and recurrent nerve palsy, anastomotic leak, and surgical site infection in 1 patient each. There was no procedure-related mortality. Conclusion: Robotic-assisted esophageal mobilization can be safely done without compromising the oncological safety with less postoperative pulmonary complications.
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Prognostic significance of neutrophil lymphocyte ratio in patients of carcinoma cervix treated with radiotherapy p. 92
B M. Muhammed Ali Azher, Niketa Thakur, Sonal Patel
DOI:10.4103/oji.oji_20_20  
Background: The elevated neutrophil-to-lymphocyte ratio (NLR) has been identified as a poor prognostic indicator in various malignancies. The progression of malignancies is manifested as alteration in blood counts which can be used as the prognostic markers. Aim: The aim of the present study is to analyze the effect of pretreatment NLR and other hematological variables on progression-free survival (PFS) and overall survival (OS) among cervical cancers patients. Materials and Methods: The present retrospective study enrolled 303 cervical cancer (Stage IIB–IVA) patients treated by radical radiotherapy from January 2016 to December 2018. The pretreatment values of NLR, absolute neutrophil count, and absolute lymphocyte count (ALC) were recorded for each patient and their associations with the clinicopathologic variables, PFS, and OS were analyzed. Results: The optimal cutoff value of NLR was 3.0. The median follow-up period was 19 months. On univariate analysis, PFS rates during the follow-up period were significantly lower in NLR-high versus NLR-low group (P = 0.042) and in low-ALC versus high-ALC group (P = 0.018). Multivariate Cox-proportional hazards model identified NLR and ALC as the strongest prognostic factors for PFS. On univariate analysis, OS was better for patients with the International Federation of Gynecology and Obstetrics Stage IIB versus III–IVA (P = 0.046) and ALC >2000/c.mm versus ≤2000/c.mm (P = 0.050), respectively. None of the hematological variables remained significant for OS on the multivariate analysis. Conclusion: High-NLR is associated with worse survival outcomes in cervical cancer patients. NLR and ALC are the independent prognostic factors for PFS in cervical cancer patients.
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Application of computed radiography in the quality assurance of linear accelerators in radiotherapy p. 98
Saravanan Kandasamy, Vijayaprabhu Neelakandan, Seenisamy Ramapandian, Mourougan Sinnatamby, Muniyappan Kannan
DOI:10.4103/oji.oji_34_20  
Introduction: The two mechanisms, optical and radiation fields, operate individually and independently in a Linear Accelerator and cause changes with respect to each other. The standard method for performing the quality assurance (QA) test in radiotherapy involves the irradiation of a radiographic film. In this study, we made an attempt to examine how we could maximize the benefit from an impending filmless environment in the radiotherapy QA program. Aim: The aim is to study the feasibility of using computed radiographs (CRs) in the radiotherapy QA program. Materials and Methods: In this study, the QA tests were performed in Linear accelerators Clinac 600c and Clinac iX, both from Varian Medical Systems, Palo Alto, CA, which was commissioned during September 2004 and July 2011, respectively, were used. Optical and radiation field congruence, radiation isocenter for the gantry, collimator, and couch rotational axis verification, in two linear accelerators were done using gafchromic (EBT3) films and CRs. The standard Gafchromic® EBT3 film, utilized for routine QA were used. The errors estimated were compared and analyzed. Results: The mean error estimated in the QA with both linear accelerators using both QA tools (CR and Film) ranged between 0.053 mm and 0.069 mm, and the standard deviation was estimated to be within 0.062-0.164 mm. Conclusion: The results infer that the QA done with CR is in good agreement with the film. This study poses new challenges to the researchers, task groups, and the regulatory bodies to estimate the frequency of QAs for the newer and the older machines and also, the onset of frequent QAs, once the machine becomes older.
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Induction chemotherapy in locally advanced head-and-neck squamous cell carcinoma: Real-world outcome p. 105
Vijay Gnanaguru, Manikandan Dhanushkodi, Venkatraman Radhakrishnan, Jayachandran Perumal Kalaiarasi, Arun Kumar Rajan, Gangothri Selvarajan, Sivasree Kesana, Srikamakshi Kothandaraman, Shobana Sekhar, Venktesh Vaidhyalingam, Arvind Krishnamurthi, Aswin Nagarajan, Kuluvoya Ramanaiah, Harish Kumar, Arun Kumar, Ram Madhavan, Alexander John, Rama Ranganathan, Trivadi Sundaram Ganesan, Tenali Gnana Sagar
DOI:10.4103/oji.oji_21_20  
Introduction: Patients with locally advanced head-and-neck squamous cell carcinoma (LAHNSCC) have a poor prognosis despite multimodality treatment. Aim: This study was done to assess the efficacy and toxicity of induction chemotherapy (IC) in patients with LAHNSCC. Materials and Methods: This was a retrospective study of patients with LAHNSCC who were treated with IC from May 2016 to July 2019 from a tertiary care cancer center in India. Results: A total of 26 patients were included in this analysis, with a median follow-up of 9.5 months. The majority of the patients had carcinoma of the oral cavity (96.2%, n = 25) and 1 (3.8%) had oropharyngeal cancer. The most common oral cavity subsites were buccal mucosa (65.4%) and gingivum (11.5%). Fifteen patients received a triplet regimen of IC and 11 patients received a doublet IC regimen. Among patients with an evaluable disease for response assessment (n = 21), complete response, partial response, stable disease, and progressive disease were seen in 9.5%, 66.7%, 19%, and 4.8%, respectively. Among patients with unresectable (Stage IVB) Oral squamous cell cancer (OSCCs), 40% underwent surgery. The median progression-free survival (PFS) was 8 months. Patients who underwent surgery after IC had a better PFS as compared to those who underwent nonoperative local therapy (12 months vs. 8 months). IC-induced Grade 3 or more toxicity occurred in 45% of the patients and mortality occurred in 2 patients (7.7%) due to neutropenic sepsis. Conclusion: IC is feasible in patients with inoperable LAHNSCC. Patients who underwent surgery after IC had a trend towards better PFS as compared to those who underwent nonsurgical local therapy after IC.
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Survival outcomes with docetaxel, oxaliplatin, and fluorouracil regimen for the treatment of metastatic gastric adenocarcinoma: A single-center experience p. 110
Pratik Patil, Vineet Govinda Gupta, Ranga Rao Rangaraju, Waseem Abbas, Rudra Prasad Acharya, Archit Pandit
DOI:10.4103/oji.oji_8_20  
Background: Patients with metastatic gastric adenocarcinoma have a relatively poor prognosis with a median survival of 6 months. The three-drug regimen of docetaxel, oxaliplatin, and fluorouracil (DOF) has been shown to improve survival compared to the two-drug regimen of docetaxel and oxaliplatin with similar toxicity. However, there is no published Indian experience with this regimen. Aim: The aim of this study was to evaluate the efficacy in terms of progression-free survival (PFS) and overall survival (OS) of DOF regimen for metastatic gastric adenocarcinoma patients in Indian settings. Materials and Methods: All patients with metastatic gastric adenocarcinoma who were treated with DOF regimen chemotherapy at our tertiary care center in North India from 2014 to 2018 were retrospectively reviewed. The DOF regimen consisted of docetaxel 50 mg/m2 on day 1, followed by oxaliplatin 85 mg/m2 on day 1, and 5-FU 2400 mg/m2 continuous intravenous infusion over 46 h; (cycle repeated at two weekly intervals until progression or unacceptable toxicity). The endpoints were overall response rate (ORR), PFS, and OS, which were evaluated using Kaplan–Meier analysis. Results: Fifteen patients with a median age of 52 years were identified; 73% were male. ORR was seen in 86.7% of patients (complete response: 20%, partial response: 60%, and stable disease: 6.7%) and progressive disease was seen in 13.3% of patients. With a median follow-up of 14 months, the median PFS was 7 months and the median OS was 16 months from the start of therapy. One-year PFS was 22% and 1- and 2-year OS was 79% and 26%, respectively. The most frequent Grades 3–4 adverse events in our patients being mucositis (33.3%), neutropenia (26.7%), and diarrhea (20%). Conclusion: DOF regimen is an effective and feasible regimen in patients with metastatic gastric cancer.
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Diet and gastric cancer p. 115
Khushboo Dewan, Renu Madan, Prashant Sengupta, Ashish K Mandal
DOI:10.4103/oji.oji_47_19  
Context: Gastric cancer is the fifth most common malignancy, with a high incidence in Eastern Asian countries. Diet is an important risk factor in the genesis of gastric cancer, and the fact that it is modifiable warrants it to be studied extensively in relation to various clinicopathological parameters of gastric cancer. Aims: The present study was undertaken to study the dietary habits (vegetarian/nonvegetarian) among gastric carcinoma patients in the Indian context. Materials and Methods: We studied 100 consecutive cases of gastric carcinoma excluding tumors at gastroesophageal junction. Clinical data regarding food habits in the patients were collected by personal enquiry. Pathological characteristics including size, site, gross appearance, Lauren's histological type, and the World Health Organization (WHO) histological type were noted. Data analysis was done using Chi-square test. Results: Sixty-nine percent of gastric cancer patients were vegetarians and 31% were nonvegetarians. Statistically significant association between nonvegetarian diet and gastric cancer location at the lesser curvature was found (P ≤ 0.001). No statistically significant association between diet and gross appearance, Lauren's, and WHO histological type of gastric cancer was found. Conclusions: For anatomical locations, most gastric cancers located at lesser curvature had been developed among nonvegetarian patients, whereas we did not observe diet to be related to gross appearance and histological type of gastric carcinoma.
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PROSPECTIVE STUDY Top

Sentinel lymph node mapping in early breast cancer using methylene blue dye p. 120
H T Amar Rao, Rohan Shetty, K C Jalaluddin Akbar, KB Mahesh, Jaganath Dixit, Manavalan Vijayakumar, S Gopinathan, Noor Mohammed
DOI:10.4103/oji.oji_36_20  
Background: With the introduction of the concept of sentinel lymph node biopsy (SLNB), the surgical management of the axilla has undergone a paradigm change in clinically node-negative early breast cancer, and complete axillary dissection is avoided if the sentinel lymph node (SLN) is negative for metastasis. Aim: The purpose of this study was to identify the reliability, accuracy, and safety of using methylene blue dye (MBD) in SLNB for early-stage carcinoma of the breast. Materials and Methods: A prospective study was conducted among 151 early breast carcinoma patients (T1/2N0M0) from December 2012 to February 2016. Intraoperative identification of the SLN was done by injecting 5 ml of 1% MBD into the subareolar region of the breast. All the blue-stained lymph nodes were then surgically excised and sent for frozen section examination. Results: The mean age of presentation was 54.10 years. Thirty out of 151 cases had SLN metastasis and 115 cases were negative for malignancy on the frozen section. On the final histopathological examination, 36 cases had metastasis and 115 cases were negative for malignancy. The false-negative rate was 5%. No patients developed anaphylactic/allergic or any type of skin reaction following MBD injection. The accuracy, positive predictive value, and negative predictive value of sentinel node identification using MBD were 96.02%, 100%, and 95.04%, respectively. After a mean follow-up of 10 months, no patient was found to be with ipsilateral axillary or supraclavicular recurrence. Conclusion: The use of MBD in SLNB for the diagnosis of axillary metastasis is reliable, accurate, and safe.
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Radically treated breast cancer patient's perception about routine physical follow-up visit p. 124
Chaitali Manohar Waghmare, Vandana S Jain, Arya Bhanu, Padmini H Nirmal
DOI:10.4103/oji.oji_37_20  
Aim: The study aimed to evaluate radically treated breast cancer patient's (RTBCP) perception about routine physical follow up visit (RPFUV). Materials and Methods: RTBCP who had completed treatment at least 1 year before and attended radiation oncology department for RPFUV from August 2018 to May 2019 were evaluated for the study. Patients of both sex and all age group who were declared disease free and ready to give informed written consent for the study were interviewed before and after briefing session. The briefing session included explanation of natural history of disease, long-term treatment side effects, alarming symptoms of disease recurrence, and coping up strategies. Data were collected, compiled, and analyzed using descriptive statistics. Results: One hundred and one radically treated eligible breast cancer patients were interviewed. The median age was 51 years. The female-to-male sex ratio was 100:1. Majority of the patients were Stage II (57.43%) and 67.33% of patients were from the middle socioeconomic group. The average investigation and travel cost per visit excluding food, stay, and care's cost per patient was Rs. 765(±343) and Rs. 483.7 (±400.67), respectively. Majority of the patients (63.37%) feel stressed when they plan for RPFUV. Before briefing sessions, 57.43% of patients agreed to follow-up with a local physician or telephonic follow-up. Whereas, after briefing sessions, 62.38% of patients agreed for the same. Conclusion: Routine physical follow-up visits cause psychological and financial burden on patients. There is a need to practice an alternative to routine physical follow-up visits in RTBCP along with patient's education to further improve posttreatment quality of life.
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A study on the clinical profile and treatment outcomes in gallbladder carcinoma from Northern India p. 128
Amit Sreen, Ravi K Anadure, HP Singh, Rohit Sharma, Anurag Garg
DOI:10.4103/oji.oji_39_20  
Aim: Gallbladder carcinoma (GBC) is a common cancer in women in North India. This prospective observational study aimed at systematically studying the clinical features, treatment response, and survival pattern of GBC patients, in a North Indian population. Materials and Methods: The clinical profile, staging of disease, and treatment outcomes of 116 consecutive patients with histologically confirmed GBC, presenting to a tertiary care hospital in Lucknow from June 2013 to August 2015, with a follow-up period of 2 years till August 2017, were studied. Data were captured on a predesigned study proforma and analyzed with appropriate statistical tools. Results: The median age at presentation was 60 years and 67 patients had coexisting gall stones. Patients were divided into three treatment groups for the analysis. Group A comprised patients who underwent radical cholecystectomy followed by adjuvant chemotherapy. Group B included patients who received the best supportive care and Group C consisted of patients who received palliative chemotherapy. The median overall survival (mOS) was 16, 2, and 9 months for Group A, B, and C patients, respectively. The mOS was 8 months for all patients, irrespective of treatment groups. On univariate analysis, factors having an adverse impact on mOS included obstructive jaundice, elevated liver enzymes, treatment groups, and advanced stage of disease. On multivariate analysis, only factor found significantly associated with mOS was treatment group (P < 0.05). Conclusions: GBC was found to be the second most common malignancy among females in our hospital registry with a uniformly poor prognosis. Patients receiving radical surgery and adjuvant chemotherapy were the longest survivors in this study. Better screening and early diagnosis are the cornerstones of improving outcomes in this aggressive malignancy.
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Swallowing dysfunction after head-and-neck irradiation – Is it worth the fiberoptic endoscopic evaluation of swallowing? p. 133
Romi Kant Grover, Preeti Negi, Pamela Alice Kingsley, Ashish Varghese, Uttam Braino George
DOI:10.4103/oji.oji_42_20  
Background: Treatment-related swallowing dysfunction still represents a significant clinical issue affecting the quality of life of head and neck cancer (HNC) patients following radiation therapy (RT) or chemoradiation therapy (CRT). Aim: The aim of the study was to evaluate the incidence of swallowing dysfunction following RT or CRT by fiberoptic endoscopic evaluation of swallowing (FEES) and to analyze the FEES findings in reference to patient-, tumor- and treatment-related factors. Materials and Methods: This prospective study included histopathological-proven HNC patients undergoing objective swallowing assessment by FEES at baseline, 3 months, and 6 months after receiving RT or CRT from December 2013 to November 2014. The parameters used to represent swallowing dysfunction included pooling of secretions, laryngeal penetration, aspiration, laryngopharynx reflux, and nasopharyngeal reflux. Results: A total of 34 patients undergoing a swallowing assessment schedule were analyzed. At 3-month assessment, we found swallowing dysfunction in 38.2% of cases which was more frequent in patients with oral cavity and hypopharyngeal primaries than other primary sites of HNC (P = 0.013). There was a higher chance of swallowing dysfunction among locally advanced HNC patients than early-staged patients, particularly at 3-month assessment although statistically insignificant (41.3% vs. 20%). The most frequently noted swallowing dysfunction was pooling of secretions in the vallecula and pyriform fossa. At 3 months following RT/CRT, there was an increase in the incidence of swallowing dysfunction (38.2% of patients) which subsequently decreased by 6 months (20.6% of patients). Conclusions: It is imperative to pick up the observations pointing toward the development of future swallowing dysfunction among HNC patients following RT/CRT by performing FEES, thereby reducing mortality associated with silent aspiration.
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CASE REPORTS Top

A rare case of renal cell carcinoma with venous tumor thrombus involving lumbar vein p. 138
Abhay Dinkar Mahajan, Bhushan V Dodia, Prashant P Darakh
DOI:10.4103/oji.oji_19_20  
The incidence of renal cell carcinoma (RCC) is around 3% of all cancers. Venous tumor thrombus (VTT) formation and migration are unique aspects of RCC with an incidence of 4%–10%. Venous extension into the renal vein, inferior vena cava, and cardiac extension have been well documented in RCC. Various surgical approaches, including a cardiopulmonary bypass for tumor embolus extraction, may be needed. However, VTT extending into the lumbar vein at the initial presentation is very rare. We hereby report such rarity of RCC presentation of VTT involving renal vein and lumbar vein in a 50-year-old male.
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Small-cell carcinoma of the lung with inguinal lymph node metastasis at initial presentation p. 142
Shabnum Thakur, Poorva Vias, Manish Gupta
DOI:10.4103/oji.oji_40_19  
Groin node metastases are predominantly seen in primary malignancies of infradiaphragmatic location. However, sparse cases of inguinal metastases from tumors above the diaphragm have been reported in the medical literature. Here, we report a case of small-cell carcinoma of the lung with metastatic inguinal lymph node at the initial presentation in a 57-year-old man. The case was diagnosed and managed congruously as per the stage of the disease, which was metastatic. However, the patient was died due to disease progression after 8 months of diagnosis. This case edifies to a clinical oncologist's knowledge that patients with commodious and disseminated malignancies of supradiaphragmatic location may present with lymph nodes in the inguinal region.
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Primary squamous cell carcinoma of head of the pancreas p. 145
Supratim Bhattacharyya, Padmalaya Devi, Subrat Samantara, K P Kunhi Mohammed
DOI:10.4103/oji.oji_43_20  
Primary pancreatic malignancy with pure squamous cell histology is extremely rare and has aggressive behavior with poor prognosis. The management of primary squamous cell carcinoma of the pancreas (SCCP) is poorly defined due to the paucity of data. Preoperative histological diagnosis is difficult in the majority of cases. Curative resection is the main stay of treatment, but most of the cases were found inoperable due to delayed diagnosis and dissemination of the disease at the time of initial diagnosis. Herein, we report a case of primary SCCP in a 44-year-old female located at the head of the pancreas. Her contrast-enhanced computed tomography (CECT) scan image had the findings of pancreatic head mass along with the features of atrophic pancreatitis. Whipple's procedure was performed successfully for the case with the postoperative pathological staging of PT2N0CM0 and chronic pancreatitis. However, the patient died due to sepsis on the 32nd postoperative day. The presence of atrophic pancreatitis on CECT scan and postoperative pathological findings of chronic pancreatitis suggested the development of squamous metaplasia followed by subsequent development of SCCP.
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