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   Table of Contents - Current issue
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January-June 2017
Volume 3 | Issue 1
Page Nos. 1-99

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EDITORIAL  

Lung cancer: Is biopsy mandatory p. 1
Sheh Rawat, Abhishek Puri
DOI:10.4103/2454-6798.209337  
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REVIEW ARTICLE Top

Sentinel node biopsy in vulvar cancer: A critical appraisal p. 5
Neville F Hacker, Ellen L Barlow
DOI:10.4103/2454-6798.209328  
Since the incorporation of inguinal-femoral lymphadenectomy into the management of patients with vulvar cancer in the mid-20th century, there have been attempts to modify or eliminate the groin dissection to decrease the risk of lower limb lymphedema. Early attempts were significantly flawed and resulted in much unnecessary loss of life because recurrence in an undissected groin is usually fatal. The best compromise yet to decrease the risk of lymphedema is sentinel node biopsy, but accumulated evidence now suggests that the false-negative rate for this procedure, if used for lesions up to 4 cm in diameter, is between 5% and 10%. Most women, properly informed of risks and benefits, are not prepared to take a 1% risk of dying from recurrent vulvar cancer to avoid lymphedema. This is the risk involved, assuming a false-negative rate of 5% and an incidence of positive nodes of 20%. For this reason, sentinel node biopsy should not be considered to be standard practice for patients with early vulvar cancer.
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ORIGINAL ARTICLES Top

Weekly versus biweekly high-dose rate brachytherapy schedules in carcinoma cervix following concomitant chemoradiation with paclitaxel and carboplatin p. 12
Pooja Gogia, Anil Kumar Dhull, Vivek Kaushal
DOI:10.4103/ASJO.ASJO_111_16  
Context: In the management of cervical cancer, though a number of chemotherapeutic drugs have been used for concomitant chemoradiation, paclitaxel and carboplatin have shown improved overall response rates with acceptable side effects. The use of intracavitary irradiation significantly improves survival and reduces local failures. However, the ideal time-dose-fraction schedule remains controversial with high-dose rate (HDR) brachytherapy. Aims: The aim of this study was to determine the efficacy and safety of paclitaxel and carboplatin for concomitant chemoradiation therapy and to compare the local control, toxicity, and tolerability of the two HDR brachytherapy schedules in patients of carcinoma cervix. Subjects and Methods: The patients were divided randomly into two groups of thirty patients each. Both the groups were treated with a combination of external beam radiotherapy with 50 Gy/5 weeks/25 fractions to whole pelvis along with concomitant chemotherapy. The concomitant chemotherapy schedule was injection paclitaxel (135 mg/m2) and injection carboplatin (area under the curve - 4.5 mg min/ml) at 4-week interval followed by HDR brachytherapy. Following which, patients received HDR-intracranial brachytherapy on the basis of random allocation, Group I: 6 Gy × 3 fractions (weekly) and Group II: 5 Gy × 4 fractions (biweekly). Results and Conclusion: The survival difference between the two groups (weekly and biweekly) was not statistically significant. However, Grade 2–3 rectal reactions in Group I were significantly higher than Group II (P = 0.038). The twice-weekly schedule of brachytherapy was a significant factor influencing the late complication rate but not the local pelvic control rate or overall survival rate.
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A phase III, multicentric, open-label, two-arm, parallel group, active-control, randomized, comparative clinical study to evaluate efficacy and safety of RituxiRel™ arm (rituximab) with reference arm (rituximab) in patients with non-Hodgkin's lymphoma p. 17
Prasad Dattatray Apsangikar, Sunil Chaudhry, Manoj Murlidhar Naik, Parvez Kozgi
DOI:10.4103/ASJO.ASJO_29_16  
Introduction: Non-Hodgkin's lymphoma (NHL) is the sixth most common hematological malignancy in adults, with B-cell lymphomas accounting for 85% of all NHLs. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of NHL and follicular lymphoma (FL) is the second most common form of B-cell NHL. Materials and Methods: The primary objective of this study is to assess the efficacy of Rituxirel™ arm with reference arm, whereas the secondary objective is to evaluate safety of Rituxirel™ arm with the reference arm in patients diagnosed with NHL. Results: The first patient was enrolled on April 30, 2012 and the efficacy and safety analysis was performed at 24 weeks. The objective response rate (ORR) was observed to be 87.87% in Rituxirel™ arm. 45.45% patients showed complete response and 42.42% patients showed partial response in Rituxirel™ arm. The ORR was observed to be 86.66% in the reference arm. 33.33% patients showed complete response and 53.33% patients showed partial response in reference arm in the Rituxirel™ arm, the most commonly reported treatment-emergent adverse events (TEAEs) related to blood and lymphatic system disorders were 52.94%, whereas in the reference arm, the reported TEAEs related to blood and lymphatic system disorders were 70%. Conclusion: Based on the results from the efficacy and safety analysis at week 24, Rituxirel™ arm was found to be as effective and safe as the reference arm. Rituxirel™ arm can be a prudent option to the reference arm, in patients undergoing treatment for DLBCL or FL.
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Analysis of prostaglandin-endoperoxide synthase-2 gene polymorphisms and risk of cervical cancer in an East Indian population: A case–control study p. 23
Dipanshu Sur, Ratnabali Chakravorty
DOI:10.4103/ASJO.ASJO_96_16  
Background: The prostaglandin-endoperoxide synthase-2 (PTGS-2) gene appears to play a role in inflammation or tumor and mitogenesis. Genetic polymorphisms in PTGS-2 might contribute to differential PTGS-2 expression and subsequent interindividual variability in susceptibility to cancer. Aim: The goal of this study is to identify genetic variants of PTGS-2 gene in women of East India, which may associate with risk of cervical cancer. Materials and Methods: We enrolled 200 histopathologically confirmed patients with cervical cancer (age 18–60 years) (cases) and their corresponding sex-matched 200 normal individuals (controls). To identify genetic variants responsible for cervical cancer, we performed sequence analysis of PTGS-2 genes. Questionnaire survey was conducted to comprehend the demographic data, smoking status, and cancer stage of patients. Results: The genotype frequency of rs689466 polymorphism was significantly different between case and control groups (P < 0.001). Compared with the wild-type genotype AA, the variant genotype GG was associated with 20-fold increased risk (P < 0.001; odds ratio = 20.76; 95% confidence interval [CI]: 2.86–160.73) for cancer patients. The rs5275: exon1-+837T>C polymorphism was not associated with cancer risk although this allele was correlated with decreased risk (P = 0.701; odds ratio = 0.71; 95% CI: 0.26–1.90). CC genotype was more frequently found in controls as compared with cases and showed an inverse association with the development of cervical cancer, thus suggesting a possible protective effect. Conclusions: PTGS-2 genotype rs689466:—1195A/G gene polymorphism demonstrated strongly associated with cervical cancer disease. However, exon1-+837T > C polymorphism was not associated with cancer risk in East Indian women. Further studies evaluating the role of PTGS-2 gene polymorphisms in ethnically diverse populations and a larger cohort may help in understanding the etiopathogenesis of cervical cancer in women worldwide.
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Prognostic significance of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in predicting outcomes for peritoneal carcinomatosis patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy p. 28
Wei-Liang Loh, Grace Hwei Ching Tan, Claramae Shulyn Chia, Shaun Tan, Melissa Ching Ching Teo
DOI:10.4103/ASJO.ASJO_108_16  
Background: Laboratory markers of systemic inflammation have demonstrated utility and cost-effectiveness in the prediction of clinical outcome in various malignancies. The aim of the present study is to evaluate the prognostic value of the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in peritoneal carcinomatosis (PC) patients who have undergone cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in a single institution. Methods: Data were prospectively collected from 164 consecutive patients who underwent CRS-HIPEC procedures between 2001 and 2014, where preoperative NLR and PLR were obtained. The primary endpoints in our study were overall survival (OS) and disease-free survival (DFS). DFS and OS were analyzed using the Kaplan–Meier method. The log-rank test was used to determine if there was a difference in survival between different groups of patients. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Results: A total of 144 patients underwent 152 CRS-HIPEC procedures, of which 113 females (74.3%) and 31 males (25.6%) with a median age of 51.5 (range 14–74) were included. Neither NLR nor PLR was associated with DFS on univariate analysis. On the exclusion of Peritoneal carcinomatosis index, PLR was significantly associated with DFS, and NLR was not associated with OS on univariate or multivariate analysis. PLR was associated with OS as a continuous or categorical variable with a cutoff of 160 on univariate analysis, but this association disappeared on multivariate analysis. Conclusion: This study shows that PLR may be more closely associated with recurrence risk and survival of PC patients undergoing CRS-HIPEC than NLR.
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Radio frequency ablation of osteoid osteoma in common and technically challenging locations in pediatric population p. 35
Shaileshkumar Garge, Shyamkumar N Keshava, Vinu Moses, George Koshy, Munawwar Ahmed, Suraj Mammen, Vrisha Madhuri
DOI:10.4103/ASJO.ASJO_54_16  
Context: Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there are limited data on its use in the pediatric population, especially in technically challenging locations. Objective: To assess the safety and efficacy of computed tomography (CT)-guided percutaneous RFA of osteoid osteoma in pediatric population. Subjects and Methods: From June 2009 to May 2014, 30 patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60–100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment. Results: Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients), despite the pediatric population and atypical location. One patient had persistent pain after 1 month duration and were treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of the right hand and fingers extension. No delayed complications were observed. Conclusions: CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations. Advance in Knowledge: This study showed that if technical success is 100% and if strict desired temperature (90°C) can be maintained for desired time (6 min) using controlled power (wattage) delivery (60–100 W) then high clinical success can be achieved even in pediatric population similar to adult population.
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Feasibility of molecular testing in a multicenter study with geographical variation in India: Epidermal growth factor receptor mutation as a model molecular test p. 39
Kumar Prabhash, Amit Rauthan, Senthil Rajappa, Chirag Desai, Rajesh Mistry, Amit Dutt, Anuradha Chougule, Ravi Mohan, Pratap K Das, Rajiv Kumar, Vanita Noronha, Amit Joshi, Vijay M Patil, Binay Swarup, Anil Kukreja
DOI:10.4103/ASJO.ASJO_104_16  
Context: Trends in epidermal growth factor receptor (EGFR) mutation based on ethnicity assist the initial selection of targeted therapy regimen. Reported incidence of EGFR mutation in Indian NSCLC patients is variable, ranging from 22% to 51.8%. Aim and Settings and Design: This multicenter, noninterventional study evaluated the prevalence of EGFR mutation in Indian NSCLC patients, its association with patients' demographics, and for the first time used a central laboratory for molecular testing. Subjects and Methods: Tissue samples from 252 NSCLC patients were tested at a Central Laboratory at Tata Memorial Hospital. Statistical Analysis Used: Patient demographics, baseline characteristics including smoking status from routine examination were recorded in a single visit. Chi-square or Fisher's exact test was used for association of EGFR mutation status with gender, age, smoking status, and histological subtypes. Results: The prevalence of EGFR mutation in Indian NSCLC patients was 23.4%. Among these, 55.9% patients had mutations in exon 19, 39% in exon 21, and 1.7% in exon 18. The incidence of EGFR mutation was higher in females than males (32.5% vs. 18.9%, respectively), and in 30.6% patients that had never smoked, 26.3% smokers, and 5.8% former smokers. The mean duration of transportation of tissue samples to the central laboratory was 48 h with an average turnaround time of 5 days for molecular testing. Conclusions: Molecular testing at a central laboratory is a feasible option in India. Prevalence of EGFR mutation in Indian NSCLC patients was similar across western and southern centers in India. A statistically significant association between EGFR mutation and gender as well as the smoking status of the patients was observed. Majority of the patients had in-frame deletions in exon 19.
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Molecular epidemiological study of microtubule-associated protein-like 4-anaplastic lymphoma kinase fusion gene using immunohistochemistry as a cost effective alternative to fluorescence in situ hybridization for Indian patients with adenocarcinoma lung p. 45
Anurag Mehta, Ullas Batra
DOI:10.4103/ASJO.ASJO_116_16  
Background: With fluorescence in situ hybridization (FISH) as the main-stay for the detection of anaplastic lymphoma kinase (ALK) rearrangements, the ALK Break Apart FISH Probe Kit has become a Food and Drug Association-approved companion diagnostic for targeted therapy with the ALK inhibitor crizotinib in lung cancers. The objective of this molecular epidemiological study was to estimate the prevalence of microtubule-associated protein-like 4-ALK (EML4-ALK) fusion gene using immunohistochemistry (IHC) as a cost effective alternative to FISH for Indian patients with nonsmall-cell cancer (NSCC)-adenocarcinoma, favor adenocarcinoma lung and NSCC- Not otherwise specified (NOS). Materials and Methods: Patients with NSCC-adenocarcinoma, favor adenocarcinoma lung, and nonsmall cell lung cancer-NOS histology were considered for this study. Permission was obtained from the Ethics Committee before the start of the study. Clinical characteristics and treatment details were collected from the patient's medical records. IHC analysis was performed using a Ventana automated immunostainer (Benchmark XT). Detection was performed using OptiView DAB Detection and Amplification Kit. Results: A total of 200 NSCC-adenocarcinoma, favour adenocarcinoma and NSCC-NOS patients were included in the study. There were 122 (61%) men and 78 (39%) women with a median age of 57 years. Of the 200 patients, 43 (21.5%) were nonsmokers and 175 (87.5%) had Stage-IV disease at the time of initial diagnosis. 48 (24%) cases were positive for epidermal growth factor receptor mutations, whereas EML4-ALK fusion gene was present in 27 (13.5%) patients. 25 of the 27 patients with ALK positivity received crizotinib therapy. Conclusions: The incidence of EML4-ALK gene fusions (13.5%) in this Indian population is four-fold high than the previous reported incidences and supports the claim of several recent studies that a relatively new ALK clone, 5A4, and D5F3 from Leica/Novocastra and cell signaling technology/Ventana, respectively can accurately identify ALK rearranged lung adenocarcinoma. The inclusion of IHC for the detection of EML4-ALK gene fusions as a low cost alternative seems justified in low resource setting.
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Is simultaneous surgery for nodes and primary in carcinoma penis safe? p. 50
Senthil Kumar Azhisoor Chandrasekhar, Kathiresan Narayanswamy
DOI:10.4103/2454-6798.209329  
Introduction: Historically, the combination of primary and nodal surgeries for carcinoma penis is thought to increase the morbidity and hospital stay. Despite the modifications in surgery including modified inguinal lymphadenectomies, morbidity of the procedure is high. Methods: A prospective, nonrandomized study to analyze a total of 56 consecutive patients from 2006 to 2009, who were evaluated and underwent surgery for primary and nodes for carcinoma penis at our center, was done. The median follow-up was 34 months (range from 12 to 48 months). The procedures included both prophylactic and therapeutic groin dissections. Various parameters were tested using SPSS version 17 statistics software. Results: Duration of drains, hospital stay, wound morbidity, and long-term complications were found to be similar in the simultaneous and staged surgery groups. The mean duration of drains for the simultaneous group of 18 patients was 12.56 days and the corresponding duration of drains for the staged surgery group of 36 patients was 12.83 days. The minor morbidity and major morbidity for the simultaneous group were 27.8% and 38.9% and the corresponding figures for the staged group were 22.2% and 44.4%, respectively. The mean and median hospital stay for the simultaneous surgery group were 21.5 and 27.5 days, respectively. The mean and median hospital stay for the staged surgery group were 17.5 and 21.36 days, respectively. The study revealed no statistically significant difference between the two groups with regard to all the above parameters. Conclusions: Simultaneous surgery for the primary and nodes in carcinoma penis is very much feasible. Simultaneous and early-staged lymphadenectomy have no difference in results with respect to drain duration, hospital stay, wound morbidity, and long-term complications. Simultaneous lymphadenectomy can be combined with penectomy both in the prophylactic and therapeutic settings.
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Clinicoepidemiological profile of hematological malignancies in pediatric age group in Ahmedabad p. 54
Zankhana Prajapati, Mayur J Kokani, RN Gonsai
DOI:10.4103/2454-6798.209330  
Background: This hematological malignancy comprises a major health problem in the society due to its high mortality and morbidity. There is a need for the accurate estimation of incidence and prevalence of acute lymphocytic leukemia (ALL), and other hematological malignancies in India to estimate the true disease burden and its impact on the population which may help in formulating the guideline which helps in better risk stratification and treatment. Unfortunately, there is a real paucity if epidemiologic data on pediatric cancers in India and particularly in several parts of Gujarat. Objectives: To find out the prevalence and other epidemiological distribution of hematological malignancy in pediatric age group patients. Furthermore, it was objected to study hematological profile and bone marrow typing in pediatric patients with hematological malignancies. Methodology: A prospective observational study carried out over 2½ years. Confirm cases of hematological malignancies were recruited from the pediatric outpatient and inpatient department. Data recorded in the preformed case record form include demographic data, data of clinical history and clinical examination, laboratory findings such as complete blood count, peripheral smear examinations, bone marrow examination for cellularity and differential count, and immunophenotyping. Fine needle aspiration cytology or biopsy of lymph node was done in suspected lymphoma patients. Observations: ALL is the most common hematological malignancy among pediatric patients in the present study with 122 out of 158 patients (77.21%). Other malignancies are acute myeloid leukemia (AML) (13.29%) and chronic myeloid leukemia (2.59%) and lymphoma (5.69%). Nearly half of the patients were below 5 years of age (51.26%) and males were predominantly affected with frequency of 77.6%. Common clinical features were fatigue, fever, loss of appetite, bone pain, petechies, hepatic and splenomegaly, pallor, and lymphadenopathy. In ALL, most common blast type in bone marrow was L1 type (86.44%), whereas in AML, it is M2 type (80%). Conclusion: The most common type of malignancies in pediatric age group is hematological malignancies with predominant variant is ALL. It is commonly affecting age below 5 years with male predominance.
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A comparative evaluation of neoadjuvant chemotherapy followed by concomitant chemoradiation versus accelerated radiation therapy versus conventional radiation therapy in a locally advanced head and neck carcinoma p. 59
Garima Malik, Anil Kumar Dhull, Rajeev Atri, Vivek Kaushal
DOI:10.4103/2454-6798.209331  
Context: Head and neck cancers (HNCs) include malignancies of oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinuses, and major and minor salivary glands. Worldwide incidence of HNC cases is 4.8%, whereas in India, it is 14.3%. Aims: Evaluation and comparison of the efficacy, tolerability, and toxicity of neoadjuvant chemotherapy (NACT) with docetaxel, carboplatin, and 5-fluorouracil (TPF) followed by concomitant chemoradiation in one group, accelerated radiation therapy (RT) in second group, and conventional RT in third group. Subjects and Methods: The present randomized prospective study was conducted on locally advanced head and neck carcinoma patients who were randomly divided into three groups. All patients received NACT with 3-weekly TPF, for 3-courses. Group I-patients received concomitant conventional RT, 64 Gy/32 fractions/6.2-week along with three weekly carboplatin 300 mg/m2 × 3-cycles. Group II-patients received accelerated RT given six fractions per week, total dose 64 Gy/32 fractions/5.2-week. Group III-patients received conventional RT, 64 Gy/32 fractions/6.2-week. Results: The overall response rate to NACT was 100% in all groups. At last follow-up, in Group I – 52% remained alive with no evidence of disease (NED), 39% remained alive with residual disease, and 9% had locoregional recurrence. In Group II – 46% remained alive with NED, 46% remained alive with disease, 8% had locoregional recurrence, whereas in Group III – 40% remained alive with NED, 44% remained alive with disease, and 16% had locoregional recurrence. Conclusions: NACT followed by concomitant chemoradiation is a better treatment protocol as compared to accelerated RT or conventional radiotherapy, in terms of better complete response rates with acceptable toxicity profile.
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Role of squamous cell carcinoma antigen in monitoring of treatment response of cervical and vaginal malignancies p. 66
Rekha Sachan, Munna Lal Patel, Meenakshi Singh, Pushpalata Sachan, Radhey Shyam
DOI:10.4103/2454-6798.209338  
Introduction: As per GLOBOCAN 2012 report Worldwide fourth most common cancer in the female is cervical cancer and approximately 528,000 new cases was found in 2012 in large majority of global burden was found in less developed country. India, the second most populous country in the world, accounts for 27% of the total cervical cancer deaths. The aim of this study was to assess the efficacy of squamous cells carcinoma antigen (SCC-Ag) in monitoring of response to treatment in cervical and vaginal cancer patients. Materials and Methods: This prospective case–control study was carried out over a period of 1 year in the Department of Obstetrics and Gynecology in collaboration with the Department of Internal Medicine and Pathology. Histopathologically confirmed study group included 8 cases of Stage I, 15 cases of Stage II, 15 cases of Stage III, 8 cases of Stage IV cervical malignancy, and 5 cases of vaginal carcinoma. About 15 healthy cervical cytology-negative women were taken as controls. Results: Out of 51 cancer cases SCC-Ag level were determined in only Stage I, II, III, and IV cases, assess the response to treatment. The mean SCC-Ag level in all four stage groups decreased significantly after post treatment as compared to pre treatment (P < 0.001) and the decrease in post treatment SCC-Ag level increased linearly with stage severity. Similarly, comparing the total or overall (Stage I + Stage II + Stage III) mean change (pre-post) in SCC-Ag level, t-test further revealed significant (P < 0.001) and decrease of 66.2% at posttreatment as compared to pretreatment. Conclusion: SCC-Ag might be a useful marker in monitoring the response to treatment.
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CASE REPORTS Top

Primary epithelioid sarcoma of scalp p. 71
Sushma G Gurwale, Charusheela R Gore, Supreet Kaur, Anjali H Deshpande
DOI:10.4103/ASJO.ASJO_113_16  
Epithelioid sarcoma (ES) is a rare mesenchymal tumor of unknown histogenesis which displays multidirectional differentiation, predominantly epithelial. They have no normal cellular counterpart and differ from both synovial sarcoma and other carcinomas. It mainly affects young adults. It has two variants, classic type and proximal type. The more common classic type presents as a slowly growing painless nodule or plaque on the distal extremities. It is rare in children and older individuals. There is male predominance. The size varies from few millimeters to several centimeters. Central deeply seated lesions in pelvis and genital tract are termed as proximal ES. It has a multinodular growth pattern and usually occurs in older patients. These are comparatively more aggressive and metastasize early. On histopathological examination, these lesions need to be distinguished from other tumors showing epithelioid morphology. Primary ES of scalp is an exceedingly rare tumor. We present a case of nodular tumor on the scalp with cervical lymph node metastasis.
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Extranodal natural killer/T cell lymphoma with cardiac and abdominopelvic nodular deposits: Unique presentation on 18-fluorodeoxyglucose positron emission tomography computed tomography scan p. 74
Shimpi Madhuri Mahajan, Sudeshna Maitra, Natasha Singh, Melvika Pereira
DOI:10.4103/ASJO.ASJO_89_16  
Cardiac lymphoma as secondary extension of non-Hodgkin's lymphoma is described in 30% of autopsies; however, a few cases are diagnosed in vivo. Primary lymphoma of the heart and pericardium is rare, accounting for 1.3% of primary cardiac tumors and only 0.5% of extranodal lymphomas at autopsy. We present a unique case of 68-year-old man diagnosed with extranodal lymphoma with cardiac and abdominopelvic nodular deposits on 18-fluorodeoxyglucose positron emission tomography-computed tomography scan findings.
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A case report of nodal marginal zone lymphoma: Diagnosis and management p. 78
Dilip Sandipan Nikam
DOI:10.4103/ASJO.ASJO_80_16  
Nodal marginal zone B-cell lymphoma (NMZL) is a rare subtype of non-Hodgkin lymphoma, usually presented at advanced stage. The treatment for NMZL is currently consistent with follicular lymphoma which includes observation for asymptomatic patients to cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or CHOP plus rituximab regimen, fludarabine or bendamustine and rituximab (B-R) for advanced, symptomatic patients. The B-R regimen is effective and could be evaluated further as the first-line therapy.
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A rare case of acute megakaryoblastisc leukemia with orbital chloroma in a non-Down syndrome child p. 81
Sahitya Koneru, Sandeep Jain, Gauri Kapoor
DOI:10.4103/2454-6798.209322  
Acute megakaryoblastic leukemia (AMKL) is a rare disease accounting for 7%–10% of acute myeloid leukemia (AML) in children. It is uncommon in children without Down syndrome (DS). Orbital chloroma is usually associated with AML M2, M4, and M5. Herein, we report the case of a 22-month-old female who was diagnosed to have AMKL with orbital chloromas and without DS. Morphology and the initial panel of immunophenotyping were inconclusive and the presence of orbital chloromas added to the ambiguity. The presence of CD61 expression and marrow fibrosis supported by hyperdiploidy helped us clinch the diagnosis. Hence, comprehensive analysis of morphology, immunophenotyping, and cytogenetics is warranted to make an accurate diagnosis of AMKL.
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Malignant intracranial hemangiopericytoma in a 22-year-old male with head injury and implications p. 84
Mukesh Sharma, Purnima Thakur, Vikas Fotedar, Anjna Sharma, Debajyoti Chatterjee
DOI:10.4103/2454-6798.209334  
We report a case of intracranial hemangiopericytoma of a young male of 22 years who presented with neurological signs of impaired memory, left hemiparesis, headache, and two episodes of focal seizures. A significant history of head trauma 9 years back was given. A space-occupying lesion was identified in the bilateral frontoparietal region. The surgical intervention involved bilateral frontoparietal craniotomy and Simpson Grade II excision of tumor. Postoperative conformal radiotherapy was administered. A marked neurological improvement was subsequently observed. Peak incidence of this disease is in the fourth or fifth decade. However, our case is an exception presenting at an age of 22 years. Associated history of head trauma has only been infrequently reported in the past.
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Concurrent T790M and L858R mutations in treatment-naïve metastatic non-small-cell lung cancer: A therapeutic challenge – current treatment strategies and promising therapies of the future in a nutshell p. 87
MC Suresh Babu, K Govind Babu, KN Lokesh, LK Rajeev, Gita R Bhat
DOI:10.4103/2454-6798.209336  
De novo (pretreatment) epidermal growth factor receptor T790M mutation in non-small-cell lung cancer (NSCLC) is rare when detected by standard genotyping methods. We present a case of concurrent de novo T790M and L858R mutations detected by direct sequencing in treatment-naïve metastatic NSCLC. This case is worthy of mention as the presence of this mutation has a bearing on the choice of treatment. This article aims to evaluate the clinical outcome for metastatic NSCLC with de novo T790M mutation and formulate an optimum treatment plan in this clinical scenario. The novel targeted therapy agents have also been reviewed.
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Colonic adenocarcinoma presenting as hemophagocytic syndrome p. 92
Murtaza Ali, Siddharta Jain, Naveet Wig, Ashustosh Biswas, Arvind Kumar, Kuldeep Kumar
DOI:10.4103/2454-6798.209332  
Hemophagocytic syndrome (hemophagocytic lymphohistiocytosis [HLH]) is a rare and potentially fatal disorder characterized by pathological immune activation associated with primary familial disorder, genetic mutation or occurring as a sporadic condition. The later can be secondary to infections, malignancies, or autoimmune diseases. Malignancy-associated HLH is commonly seen in hematological malignancies and rarely with solid organ tumors. We report a case of adenocarcinoma colon presenting as hemophagocytic syndrome. To the best of our knowledge, it is the first case report of HLH secondary to carcinoma colon.
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Single injection thoracic paravertebral block (TPVB) for breast surgery in morbidly obese patient p. 96
Anita Kulkarni, Vedapadmapriya Selvakumar, Namrata Gupta
DOI:10.4103/ASJO.ASJO_81_15  
Morbidly obese (MO) patients with associated restrictive airway disease, obstructive sleep apnea, and coronary artery disease pose challenge to an anesthesiologist. Regional block combined with general anesthesia (GA) is the anesthetic technique of choice as it will decrease the requirement of opioids, anesthetics, and postoperative respiratory depression. A MO patient for modified radical mastectomy was successfully managed with single-injection thoracic paravertebral block and conventional GA.
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