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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 57 | Issue 2
Page Nos. 121-227

Online since Monday, May 18, 2020

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EDITORIAL  

Pulmonary metastasectomy in osteosarcoma: Finite disappointments to keep alive the infinite hope! p. 121
Avinash Pande, Jyoti Bajpai
DOI:10.4103/ijc.IJC_842_18  PMID:32445313
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SPECIAL ARTICLES Top

The COVID-19 pandemic and the Tata Memorial Centre response Highly accessed article p. 123
The Tata Memorial Centre COVID-19 Working Group
DOI:10.4103/ijc.IJC_250_20  PMID:32445314
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Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario p. 129
Tushar A Narain, Gagan Gautam, Amlesh Seth, Vikas K Panwar, Sudhir Rawal, Puneet Dhar, Harkirat S Talwar, Amitabh Singh, Jiten Jaipuria, Ankur Mittal
DOI:10.4103/ijc.IJC_356_20  PMID:32445315
The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.
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REVIEW ARTICLES Top

Rare cancers in India: A road less travelled p. 139
HS Darling, Sameer Rastogi
DOI:10.4103/ijc.IJC_384_19  PMID:32445316
Globally, rare cancers as a group are commoner than any single common cancer. They represent an unmet medical need, and this issue gets further amplified in India due to various reasons, including the limited accessibility of healthcare system to the population at large. The scarce available data yet only represents the tip of the iceberg, due to poor registration and incomplete medical cover. Rare cancers, as a consequence, are driven further away from attention of the policy.makers and financial authorities. Poor research prospectives and lesser administrative support restrict the research in this field. There is an urgent need for initiating studies exclusively on rare cancers in India, considering their prevalence and deprived management, as many countries are already pursuing work in this field. All such inadequacies ultimately affect the patient outcomes. In this review, after discussing these aspects, we suggest a stepwise approach to improve the care of rare cancers in India.
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Grossing and reporting of breast cancer specimens: An evidence-based approach p. 144
Tanuja Shet, Trupti Pai, Tabassum Wadasadawala, Nita Nair, Seema Gulia
DOI:10.4103/ijc.IJC_157_20  PMID:32445317
A histopathology report offers important prognostic and predictive information that helps plan systemic therapy in breast cancer. However, in many cases a pathologist fails to provide relevant information chiefly due to the lack of awareness of the impact of these parameters in clinical decision-making. This review seeks to put forth common practice points in grossing and reporting of specimens harboring breast cancer with focus on latest revisions in the same. Just as it is important to document tumor size, tumor type, margins, estrogen receptor/progesterone receptor, and human epidermal growth factor (ER/PR/HER2) in breast cancer, we need to also focus on sentinel node grossing, nodal burden, size of nodal metastasis, and extranodal extension. In parallel, increasing number of patients are getting neoadjuvant chemotherapy in breast cancer and points in grossing and reporting of such specimens are also alluded to. This article will serve as reference guide to pathologists on what we do and why we do the same.
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GI CANCER Top

An analysis of adjuvant treatment strategies in operated pancreatic cancer patients: An Izmir oncology group study p. 158
Umut Varol, Yusuf Uzum, Adem Sengul, Ugur Bayram Korkmaz, Murtaza Parvizi, Murat Akyol, Halil Taskaynatan, Tarik Salman, Utku Oflazoglu, Yasar Yildiz, Ahmet Alacacioglu, Yuksel Kucukzeybek, Mustafa Oktay Tarhan
DOI:10.4103/ijc.IJC_318_18  PMID:32445318
Background: Adjuvant treatment is necessary in pancreatic cancer patients, but the optimal approach is not clear yet. Our aim was to explore the effectiveness of adjuvant treatment modalities in patients with operated pancreatic cancer. Methods: There were five groups of patients operated for primary pancreas adenocarcinoma. The first two groups included patients who were treated with only adjuvant chemotherapy or radiotherapy. The patients in third group had received combination chemotherapy and radiotherapy either sequentially or concomitantly. The fourth group was composed of patients who were treated with adjuvant chemotherapy after concurrent chemoradiotherapy, whereas the patients in the fifth group were only observed after surgery without any adjuvant treatment. Results: There were 83 operated pancreatic cancer patients available for analysis. Median age of the patients was 63 years (range, 40–82 years). There were 55 patients who had local disease recurrence (n = 14) or metastasis (n = 41) during or after adjuvant treatment. The median overall survival for all patients was 14 months. When we compared the median survival of patients who had any adjuvant treatment with the patients treated without any adjuvant therapy, we found a significant statistical difference between the groups (32.4 vs 6.5 months; P = 0.000). In addition, survival of each treatment group was also compared with each other but we did not find any significant statistical difference. Conclusions: Our result suggests that any adjuvant therapy in the treatment of pancreatic cancer patients is important. However, we could not find any superiority between adjuvant treatment modalities.
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COMMENTARY ON THE IZMIR STUDY Top

Commentary on adjuvant therapy in operated pancreatic carcinoma by the Izmir group p. 164
Rushabh Kothari
DOI:10.4103/ijc.IJC_569_19  PMID:32445319
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High potential of SOX21 gene promoter methylation as an epigenetic biomarker for early detection of colorectal cancer p. 166
Keivan Moradi, Esmaeil Babaei, Nayebali Rezvani, Reza Safaralizadeh, Homayoun Bashiri, Mohammad Ali Hosseinpour Feizi
DOI:10.4103/ijc.IJC_542_18  PMID:32445320
Background: Despite the advances in screening during the past decades, colorectal cancer (CRC) still is a leading cause of cancer deaths worldwide. Therefore, the development of new diagnostic methods is necessary. Aim: The aim of this study was to compare methylation changes of SRY-Box 21 (SOX21) gene promoter in tumor tissues and their normal adjacent mucosa in patients with CRC and to examine the relationship between the methylation levels and demographic/clinicopathological factors. Materials and methods: A total of 41 CRC patients participated in the present study. After the extraction of DNA and bisulfite treatment of the samples, the methylation levels were determined by using the MethyLight method. Statistical analysis: Two-sided Mann–Whitney U test was used to compare the median level of methylation in tumor tissues and their adjacent normal mucosa. Results: The methylation rates in tumor tissue samples were significantly higher compared to their adjacent normal mucosa (P < 0.0001). No association between demographic/clinicopathological factors and methylation status observed in tumor tissues. A receiver operating characteristics curve was constructed and tissue samples exhibited a sensitivity of 80.5% and specificity of 97.6% for SOX21 promoter methylation. Conclusion: The results of this study indicated the high potential of SOX21 gene promoter methylation as a candidate noninvasive diagnostic biomarker in stool and plasma of colorectal cancer patients. However, further studies with larger sample sizes are required to evaluate the specific role of SOX21 methylation as a biomarker for early detection of CRC.
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BONE AND SOFT TISSUES Top

Pulmonary metastasectomy in primary extremity osteosarcoma: Choosing wisely, along with a brief review of literature p. 172
Vishnu Ramanujan, Arvind Krishnamurthy, Karthik Venkataramani, Chandra Kumar
DOI:10.4103/ijc.IJC_497_18  PMID:32445321
Background: Despite the advances in systemic treatment, about 30%–40% of the patients with extremity osteosarcomas relapse and more than 80% of these relapses localize in the lungs. Our understanding of the management of pulmonary metastases from extremity osteosarcomas is largely based on retrospective data from single institutions or compiled from registries; hence, there is great degree of variability in the reported management of pulmonary metastasis in patients with osteosarcomas. Aims and objectives: To analyze the demographic profile, disease characteristics and survival outcomes of patients who had undergone potentially curative pulmonary metastasectomies from extremity osteosarcomas. Materials and methods: Retrospective analysis of the 37 patients with resectable pulmonary metastasis (both synchronous and metachronous) from osteosarcoma of the extremity, treated from January 1, 2003 to December 31, 2017 at a tertiary regional cancer center in South India. Results: The median overall survival (OS) of our patient cohort was 38 ± 2.7 months. The 2-, 3-, and 5-year OS were 86 ± 5.8%, 60.8 ± 8.6%, and 20.7 ± 7.4%, respectively. A formal analysis of the various prognostic factors revealed disease-free interval >2 years, completion of the planned systemic chemotherapy, and absence of pulmonary recurrence post-metastasectomy to be significantly influencing the survival outcomes. Conclusion: Our study reiterates the need for consideration of pulmonary metastasectomy in carefully selected patients of extremity osteosarcomas. There is a paucity of data on pulmonary metastasectomies from India and our cohort is possibly the largest series for pulmonary metastasectomies from an osteosarcoma primary. In routine clinical practice, we recommend that the final decision to proceed with pulmonary metastasectomy should ideally be taken by a multidisciplinary tumor board on a case-by-case basis.
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GYNECOLOGIC ONCOLOGY Top

Comparison of thermoplastic masks and knee wedge as immobilization devices for image-guided pelvic radiation therapy using Cone Beam Computed Tomography p. 182
Mridul Anand, Ankita Parikh, Sonal P Shah
DOI:10.4103/ijc.IJC_602_18  PMID:32445322
Introduction: Pelvic radiotherapy is generally performed with the use of an immobilization and positioning device. Aim and objective: The objective of the study was to ascertain and compare setup errors between the two positioning devices. Materials and methods: A total of 35 patients of stage II and III cervical cancers were enrolled in the study and divided into two groups, one using knee wedge and the other using thermoplastic pelvic mask as an immobilization device. Radiation was planned by four field box conformal technique. The random and systematic setup errors were then calculated for each patient in both the groups in the mediolateral (ML), superoinferior (SI), and anteroposterior (AP) directions. Results: The translational mean setup variation in the lateral, longitudinal, and vertical direction is 0.17 ± 0.24, −0.12 ± 0.48, and −0.18 ± 0.27 cm for thermoplastic pelvic mask and −0.03 ± 0.26, −0.04 ± 0.48, and −0.09 ± 0.37 cm for knee wedge, respectively. The systematic setup error and random errors were 0.24, 0.48, 0.27 cm and 0.31, 0.60, and 0.40 cm for thermoplastic mask and 0.26, 0.48, and 0.37 cm and 0.38, 0.37, and 0.45 cm for knee wedge in ML, SI, and AP axis, respectively. The one way analysis of variance test was applied to compare the setup errors in between the three axes for both the immobilization devices. To compare the positioning accuracy of thermoplastic mask and knee wedge, Student's t-test was applied. Both the tests were found to be insignificant (P value > 0.05). Conclusion: Thermoplastic mask and knee wedge are equally effective as immobilization devices for treating cervical cancers with conformal techniques.
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BREAST CANCER Top

Genetic polymorphism of hOGG1 ser326cys and its association with breast cancer in Jammu and Kashmir p. 187
Ashna Nagpal, Sonali Verma, Ruchi Shah, Ghulam R Bhat, Amrita Bhat, Divya Bakshi, Bhanu Sharma, Sandeep Kaul, Rakesh Kumar
DOI:10.4103/ijc.IJC_676_18  PMID:32167073
Background: 8-Oxo-7, 8-dihydro-2'-deoxyguanosine (8-oxodG) is a potent DNA damage marker that leads to cellular oxidative stress. It is a DNA-repair enzyme that participates in “8-oxodG” DNA adducts removal. Previous studies show weak associations of rs1052133 (hOGG1) in breast cancer patients of Northern India. We performed this study to explore the variant rs1052133 (hOGG1) with breast in the population of Jammu and Kashmir (J and K). Method: A polymerase chain reaction–restriction fragment length polymorphism -based single-nucleotide polymorphism (SNP) genotypic study was carried out in peripheral blood samples of 165 breast cancer patients and 200 healthy controls, using specific primers. Sanger sequencing verified the results. Results: hOGG1-Ser326Cys polymorphism occurred frequently in cases as compared with controls. Data were evaluated by SPSS V.13 software, following Hardy–Weinberg equilibrium (P = 0.002 at OR 2.57; 95% CI [1.68–3.93]), which showed that the SNP rs1052133 had a significant association with increased risk of breast cancer. Conclusion: Overall, the results of this analysis show that the hOGG1-Ser326Cys polymorphism may be associated with an increased risk for breast cancer in the J and K population.
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Study of ER, PR, HER2/neu, p53, and Ki67 expression in primary breast carcinomas and synchronous metastatic axillary lymph nodes p. 190
Tejal Abasaheb Khande, Avinash R Joshi, Siddhi Gaurish Sinai Khandeparkar, Maithili M Kulkarni, Bageshri P Gogate, Aniket R Kakade, Piyush D Sahu, Chaitnya D Khillare
DOI:10.4103/ijc.IJC_610_18  PMID:32445323
Background: Breast cancer (BCA) is the second most common cancer among women in India and accounts for 7% of global burden of BCA. The axillary lymph node status is an independent prognostic factor. The combined estrogen receptor (ER), progesterone receptor (PR), and HER2/neu biomarker expression is a predictor of BCA status for therapeutic guidance. Studies have demonstrated that these biomarkers are unstable throughout their tumor progression. Varying concordance and discordance rates in the biomarker expression between primary breast carcinoma (PBC) and metastatic axillary lymph node (MALN) status are reported. Aim: This study was conducted for studying and comparing the expression of immunohistochemistry (IHC) markers, i.e., ER, PR, HER2/neu, p53, and Ki67 between PBC and their corresponding MALN for prognostication and therapeutic purpose. Methods: Sixty cases of PBC with metastasis to axillary lymph nodes diagnosed between years 2008 and 2014 were included in the study. A technique of manual tissue array was employed for cases subjected to IHC. Analyses of the expression of IHC markers were attempted between the PBC and their corresponding synchronous MALN and classified as concordant or discordant. Results were subjected to statistical analysis. Results: Substantial agreement was observed for biomarker ER, PR, HER2/neu, p53, and Ki67 expression between PBC and MALN with k-value 0.79, 0.75, 0.89, 0.7, and 0.6, respectively. Conclusion: There was high concordance for the IHC markers: ER, PR, HER2/neu, p53, and Ki67 expression in matched pairs of PBC and corresponding synchronous MALN. However, the discordance noted in small subgroups cannot be overlooked. Thus, there is a need to perform ER, PR, HER2/neu, p53, and Ki67 IHC studies routinely in both PBC and MALN to help design therapies that are tailored to target the specific tumor clones and render maximum benefit to patients.
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MCQS Top

MCQs on “Study of ER, PR, HER2/neu, p53, and Ki67 expression in primary breast carcinomas and synchronous metastatic axillary lymph nodes” p. 198
HS Darling, S Jayalakshmi, Pradeep Jaiswal
DOI:10.4103/ijc.IJC_306_20  PMID:32445324
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CASE REPORTS Top

Chronic neutrophilic leukemia presenting as secondary gout: Report of a rare myeloproliferative disorder p. 201
Sugandha, Naveen Kakkar, M Joseph John
DOI:10.4103/ijc.IJC_560_18  PMID:32445325
Chronic neutrophilic leukemia is a rare leukemia seen in middle aged and elderly people, characterized by neutrophilic leukocytosis with no significant increase in granulocytic precursors. The chief criteria for diagnosis include total leukocyte count ≥25 × 109/L, >80% of white blood cells being mature neutrophils (segmented and band forms), immature granulocytic precursors ≥10% in the peripheral blood, and hypercellular marrow. In addition to this, there must be no evidence of dysplasia, monocytosis or BCR-ABL1, PDGFR-A, PDGFR-B, or FGRF-1 rearrangements. Moreover, the cause of neutrophilia should not be attributed to any other myeloproliferative disorders or to physiologic neutrophilia.We present two patients with this rare disorder who presented with gout as the initial symptom.
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Neuroendocrine tumor in a lesser sac bronchogenic cyst – A hitherto unreported entity made rarer by concomitant hepatic hydatid cyst p. 205
Neha Bakshi, Shashi Dhawan, Pratishtha Sengar, Ushast Dhir
DOI:10.4103/ijc.IJC_749_18  PMID:32445326
Intra-abdominal bronchogenic cysts are rare entities and only a handful of cases occurring within the lesser sac have been described. Further, the development of malignancy in a bronchogenic cyst is exceptional and one arising in a lesser sac has so far not been reported. We present herein an account of a 44-year-old man who presented with recurrent upper abdominal pain. Investigations revealed a mass in the lesser sac and a hydatid cyst in the liver. The histopathological examination of the excised mass showed bronchogenic cyst, with a neuroendocrine tumor of intermediate grade arising in its wall. Concomitant presence of hydatid cyst in the liver made this case even more unusual.
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Unusual cause of seizure in a child: Intracranial calcified metastasis of osteosarcoma p. 209
Venkatesh Hosur Ananthashayana, Manisha Jana, Sumeet S Malapure, Arun K Gupta
DOI:10.4103/ijc.IJC_796_18  PMID:32445327
Intracranial parenchymal calcification has both benign and malignant etiologies. Calcifications by malignant etiologies are comparatively rare. Malignant calcification has numerous causes. Calcified brain metastasis from osteosarcoma is one such cause. We present histopathologically confirmed intracranial calcified metastasis in a 10 year old girl. This girl had received treatment for primary osteosarcoma of the left femur with pulmonary metastases. Radiological imaging with Positron emission tomography–computed tomography revealed an intracranial calcified lesion in the frontal lobe and she was successfully operated for the same. The malignant causes of intracranial calcifications are reviewed and radiological differential diagnoses of malignant intracranial calcifications are discussed in this case report. Prior history, strong clinical suspicion, and radiological imaging are needed to arrive at the diagnosis of intracranial calcified metastasis from primary osteosarcoma of the appendicular skeleton.
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VIEWPOINT Top

A wrong diagnosis p. 212
Neha Chauhan
DOI:10.4103/ijc.IJC_418_19  PMID:32445328
Cancer therapy is undergoing rapid advancements and many of the conditions that were incurable earlier can now easily be treated. Making a “correct diagnosis” is the first step in the ladder towards treating the disease. However, once diagnosed, “breaking bad news” to the patient and his family that he/she has cancer is still a big challenge as it is a life-changing event not only for the patient but their families as well. The following article narrates an incident dealing with the significance of diagnosing the condition accurately and that of “breaking bad news”. It gives an insight into the emotional ordeal that clinicians dealing with terminal-illnesses like cancer go through on a daily basis while trying to diagnose it and communicating it to the patient and his family.
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LETTERS TO THE EDITOR Top

Therapeutic results in three cases of ganglioneuroblastoma associated with opsoclonus myoclonus ataxia syndrome p. 216
Ivan A Shtarbanov, Ivan K Boronsuzov, Ivan R Chakarov, Dobrin N Konstantinov
DOI:10.4103/ijc.IJC_115_19  PMID:31898588
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Caring of cancer patients during COVID-19: A real-life challenge p. 218
Shreya Das Adhikari, Nitin Gupta, Atul Sharma, S V S Deo, Sushma Bhatnagar
DOI:10.4103/ijc.IJC_342_20  PMID:32445329
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PERSPECTIVE Top

Time, distance, shielding and ALARA; drawing similarities between measures for radiation protection and Coronavirus disease pandemic response p. 221
Ashutosh Mukherji, Tejpal Gupta, Jai Prakash Agarwal
DOI:10.4103/ijc.IJC_343_20  PMID:32445330
The practice of radiation oncology requires stringent adherence to specific steps and principles designed to minimize exposure of an individual to unnecessary doses of radiation. The basic principles of such measures to reduce the risk of exposure and limit the doses of irradiation follow the “as low as reasonably achievable ” or ALARA principle by using the concepts of time, distance and shielding. Potential exposures in radiation oncology are controlled through combination of optimal design and installation of radiation delivery equipment with well-defined standard operating procedures (SOPs). In the modern era of viral pandemics, similar principles can also be applied toward prevention of viral transmission and protection of populations at risk. In the ongoing COVID-19 pandemic, the probability of an individual getting infected is dependent on the viral load that an individual is exposed to in public spaces over a period of time. All prevention and control measures are based on preventing any such exposure to the virus, that can be achieved through limiting space for movement of the virus, using barriers and increasing distance to vulnerable surfaces, and limiting the duration of exposure. Apart from adhering to the laid-down provisions of a lock-down, preventive measures recommended for the general public include maintaining hand-hygiene, social distancing, and using facemasks to break the chain of transmission. Appropriate triage and customization of treatment protocols can help curtail hospital visits and time-spent by cancer patients during pandemic times, thereby reducing their risk of exposure as well as allowing efficient utilization of resources. The outbreak of the contagious COVID-19 pandemic threatens to disrupt healthcare systems globally with its unprecedented challenges. However, despite all the difficulties and hardships, it has also enabled new ways of learning and communication, which are likely to persist even in the post-COVID world.
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NEWS Top

News from the world of oncology p. 224

DOI:10.4103/ijc.IJC_386_20  
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