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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 3 | Issue 2
Page Nos. 101-157

Online since Friday, February 2, 2018

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ORIGINAL ARTICLES  

Hypofractionation in postmastectomy breast irradiation. How safe are we in using standard tangentials? Highly accessed article p. 101
Bindhu Joseph, Nisma Farooq, Muhammed N Shafeeque, S Sathiyan, V Lokesh, C Ramesh, CR Vijay
DOI:10.4103/ASJO.ASJO_53_17  
Aim: Hypofractionation in breast radiotherapy is gaining increasing relevance in routine clinical practice; however, gray areas remain on its safety. Majority of data regarding the same pertains to the treatment of the conserved breast. This study aimed to compare the use of standard wedge-based tangentials (two-dimensional [2D] TW) versus 3D conformal radiotherapy field in the field (3DCRT FIF) with the intent of evaluating if the latter would provide a dosimetric advantage. Materials and Methods: Twenty-six postmastectomy patients were enrolled in this study. Comparative plans using 2D TW and 3DCRT FIF were generated to deliver 50 Gy in 25 fractions. Dosimetric parameters pertaining target dose, Homogeneity Index (HI), Conformity Index , and dose to normal structures were compared and analyzed. The parameters that achieved significance were evaluated using the hypofractionated plan. Results: The 3DCRT FIF plan showed better planning target volume coverage, V95%(P < 0.001) and less cardiac dose (V30and MD) as well as lung V20,V30,MD, and V5for both lungs (P < 0.001). The dose to the left descending coronary artery (LAD) was also less with a trend toward significance (P = 0.07). The 3DCRT FIF plan also improved HI (P = 0.02). However, the high-dose volume V107%and radiation exposure were not higher. The significant parameters were evaluated in the hypofractionated schedule of 40 Gy/15 Fr. The MD to the heart was 8.96 Gy in FIF plan versus 20.16 Gy in TW plan. The average V20to the ipsilateral lung was 37.8% versus 65.2%. The average dose to the contralateral breast was 50% less, i.e., 3.92 Gy versus 8.96 Gy. Conclusion: The results of this study suggest that there would be a significant benefit of using 3DCRT FIF plans for patients being considered for hypofractionated radiotherapy in the postmastectomy setup.
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Efficacy of acoustic radiation force impulse elastography in differentiation of benign and malignant lymph nodes p. 106
Rashmi Sudhir, M V. T Krishna Mohan, Bogala Shilpa, Veeraiah K Chaudhary
DOI:10.4103/ASJO.ASJO_48_17  
Aims and Objectives: Aim of this study was to assess the clinical usefulness of Acoustic Radiation Force Impulse (ARFI) elastography imaging in differentiating benign and malignant/metastatic superficial nodes. Methods and Materials: ARFI elastography (Siemens Medical Solutions, Mountain View, CA) using Virtual touch Tissue Imaging (VTI) technique was performed and Shear wave velocity (m/sec) was measured in 85 patients (mean age, 49 years; range, 16–72 years) with 126 lymph nodes (96 axillary, 21 cervical and 9 inguinal nodes) which were biopsied and histo-pathologically correlated. Results: Of 126 nodes, 71 were benign (64 reactive and 7 koch's) and 55 were malignant (40 metastases and 15 lymphoma). The mean ARFI value of malignant nodes ±SD (4.42 ± 2.60) were significantly higher than the benign nodes (1.76 ± 0.44), with P <0.001. With the use of Receiver Operating Characteristic (ROC) curve, the cut off SWV was estimated to be 2.45m/s with sensitivity of 83.6%, specificity of 91%, and accuracy of 93.7 % while the conventional US based short axis diameter (SAD) measurement with cut off value of 10mm, showed the sensitivity of 62 %, specificity of 87% and accuracy of 87%. Conclusion: Acoustic radiation force impulse elastography is feasible for superficial lymph nodes and provides quantitative elasticity measurements, which may complement B-mode ultrasound and potentially improve the differentiation of benign and malignant/metastatic lymph nodes.
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Computed tomography-guided Tru-cut biopsy of lung mass, as an important diagnostic tool: Histopathological characteristics, age, sex distribution, and risk factors in Misurata Cancer Center, Libya p. 111
Mohamed Alhashmi M. Sidoun, Yasin Topov, Mohamed A Elfageh, Noura A Mansour, Abdullah A Jwaid, Alhadi M Jahan, Mussa A Alragig
DOI:10.4103/ASJO.ASJO_12_17  
Background: Lung biopsies may be classified according to the method of access or by the reason for biopsy. Tru-cut biopsy is a simple, relatively safe, rapid, and reliable technique for the diagnosis of lung mass lesions, particularly with the aid of computed tomography (CT) scan. This procedure is commonly used worldwide to detect different kinds of lung tumors, but its usefulness in Libya is not yet studied. Objectives: The aim of this study was to assess the usefulness of Tru-cut biopsy as a diagnostic method in lung tumors and also to determine the incidence of lung cancer in various ages and sex groups and in relation to smoking data. Patients and Methods: Retrospective study was done on 136 patients who underwent CT-guided Tru-cut biopsy from January 2012 to March 2015. The included patients have lung mass lesions suspected to be neoplastic according to chest radiograph and/or CT scan. Results: We found biopsies and histopathology reports of 136 cases. The patients' age was from 20 to 85 years with the peak incidence in the sixth and seventh decades. The benign lesions were 18 (13.23%), and malignant lesions were 118 (86.76%) documented microscopically. The most common tumor was squamous cell carcinoma (25.17%), followed by adenocarcinoma (23.02%) and small cell lung carcinoma (17.26%). Nonspecific inflammation was found in 8.63%. Conclusion: CT-guided Tru-cut biopsy is a simple, safe, and reliable procedure with high diagnostic accuracy for the diagnosis and subtyping of lung cancer. The definitive result of malignancy is a base for correct decision for the patient's treatment after careful clinical correlation with performance state, radiology findings, and complete serological investigations.
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Tumor-associated macrophages: Oblivious confederates in invasive mammary carcinoma p. 116
Imtiaz Ahmed, Manoj Gopal Madakshira, Puja Dudeja, Reena Bharadwaj
DOI:10.4103/ASJO.ASJO_46_17  
Background: The infiltrating margins of carcinomas are associated with presence of inflammatory cell infiltrate which are an integral part of the tumor microenvironment. Amongst the inflammatory cells, Tumor Associated Macrophages (TAMs) play a key role in the tumorigenesis. This study elucidates the density of TAMs in invasive mammary carcinomas and attempts to establish aa association with the following pathological variables: tumor size, histological grade, nodal status, hormonal expression status and Her2Neu overexpression. Materials and Methods: 90 diagnosed archival cases of invasive mammary carcinomas at a tertiary care centre were included. Density of TAMs was assessed by using CD68 which is a pan-macrophage marker by immunohistochemistry on the archival tissue blocks. The density TAMs (CD68 positive cells) was dichotomised into high (>50 CD68 positive cells/ HPF) and low (<5050 CD68 positive cells/ HPF) and compared with the above mentioned pathological variables using appropriate statistical tests. Results: The density of TAMs was significantly higher around the infiltrating edge of the carcinoma in comparison to the adjoining normal terminal duct lobular units. The density of TAMs was more in the infiltrating edge of the tumor than within the tumor nodule/nests. A higher TAM density showed a significant association in tumors having large tumor size, higher histological grade, nodal metastasis, absence of ER and PR expression and Her2Neu overexpression (p value <0.05). Conclusion: TAMs play an important role in tumor progression in invasive mammary carcinomas. This is as a result of the multiple roles enacted by TAMs in the various stages of tumor development starting from tumor growth, invasion, angiogenesis and metastases. Targeted therapy against TAMs has great potential in the being important components of future treatment strategies against breast carcinomas.
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REVIEW ARTICLES Top

Management of lung cancer brain metastasis: An overview p. 121
Himanshu Srivastava, Preety Negi, Pamela Alice Kingsley, Jaineet Sachdeva
DOI:10.4103/ASJO.ASJO_79_16  
With the improvements in systemic treatment for lung cancer, distant metastasis to sanctuary sites such as brain has become an increasingly more important issue. The management of these patients consists of supportive care and disease-directed treatment. Combined modality treatment (surgical resection or radiosurgery, followed by whole brain radiotherapy) of brain metastases has greatly improved the local control of disease in patients with single lesion, good functional performance status, and controlled extracranial disease as demonstrated in prospective randomized studies. For patients with multiple brain metastases, conventional fractionated whole brain radiotherapy continues to be a standard and efficacious treatment. At present, experience with the use of molecularly targeted tyrosine kinase inhibitors in nonsmall cell lung cancer patients with activating mutations in the epidermal growth factor receptor gene and anaplastic lymphoma kinase gene is growing. However, their effectiveness in patients with brain metastases is not well established. In the arena of targeted therapies, vascular endothelial growth factor pathway inhibitors such as bevacizumab have shown some activity in brain metastases. Further prospective studies are necessary to facilitate selection of patient subpopulation for targeted agents in future studies.
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Tumor motion in lung cancers: An overview of four-dimensional radiotherapy treatment of lung cancers p. 128
Anusheel Munshi, Nilaxi Khataniar, Tharmar Ganesh
DOI:10.4103/ASJO.ASJO_75_16  
Most modern radiotherapy centers have adopted contouring based treatment. Sparing of the normal structures has been made more achievable than ever before by use of technologies such as Intensity Modulated Radiotherapy (IMRT) and Image guided radiotherapy (IGRT). However, unlike, sites such as brain or head neck, thorax is a site in active motion, mostly contributed by patient's respiratory movement. 4 D radiotherapy, that addresses the issues of motion in thoracic tumours answers this critical question. The present article outlines the scope of need for 4 D radiotherapy and discusses the options available for 4 D treatments of cancer patients.
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CASE REPORTS Top

Undifferentiated pleomorphic sarcoma: Diagnosis of exclusion p. 133
Pragati S Upasham, Sharayu P Dighavkar, Prakash M Roplekar
DOI:10.4103/ASJO.ASJO_34_17  
Malignant soft-tissue tumors which were designated as malignant fibrous histiocytoma are regrouped by the WHO (in 2002) under the new entity termed as “undifferentiated pleomorphic sarcoma.”[1] It accounts for less than 5% of all adult soft-tissue sarcomas. Here, we report the lesion in a 70-year-old man who presented with high-grade undifferentiated pleomorphic sarcoma in the lower extremity.
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Maxillary metastasis from carcinoma lung: An unusual presentation p. 136
Niharika Bisht, Sankalp Singh, Arti Sarin, Deepak Mulajker, Samir Gupta, Prabha Shankar Mishra
DOI:10.4103/ASJO.ASJO_16_17  
Lung cancer is one of the most common cancers in the world affecting both men and woman. Common site of metastasis includes liver, adrenals, bone, and brain. Metastasis to the maxilla is very rare with only a few cases being reported so far. Here, we present a case of a 32-year-old male where metastatic lesion was discovered before primary tumor.
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Mammary analog secretory carcinoma parotid gland: Case report of a recently described tumor with review of literature p. 139
Vandana L Gaopande, Maithili M Kulkarni, Siddhi G.S. Khandeparkar, Avinash R Joshi
DOI:10.4103/ASJO.ASJO_61_16  
Mammary analog secretory carcinoma (MASC) is a low-grade malignant tumor of salivary glands. It is so named because of its cytohistopahological, immunohistological, and cytogenetic resemblance to secretory carcinoma of the breast. Since the first description of this tumor in 2010, about 70 cases have been reported in literature. We report a case of this recently described tumor in a 21-year-old female. The radiological diagnosis of her parotid swelling was pleomorphic adenoma. The cytological evaluation was suggestive of oncocytoma. The histopathology showed a low-grade malignant neoplasm and the differential included papillary variant of acinic cell carcinoma, oncocytic variant of mucoepidermoid carcinoma, and MASC. Immunohistochemistry confirmed the diagnosis of MASC. We have included a brief review of literature.
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Collision tumor of the urinary bladder comprising Large cell neuroendocrine carcinoma and adenocarcinoma p. 144
Jatin Sundersham Gandhi, Sunil Pasricha, Gurudutt Gupta
DOI:10.4103/ASJO.ASJO_14_16  
Large cell neuroendocrine tumors of the bladder are rare tumors. Their co-association with adenocarcinoma is even rarer. We present a third undisputed case of collision tumor comprising large cell neuroendocrine carcinoma and adenocarcinoma of the urinary bladder in a 73-year-old gentleman with a revisit to its origin and histogenesis.
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Cervical carcinoma metastasizing to uveal tissue manifesting as pseudohypopyon p. 147
Vinay Gupta, Vinod Sharma, Kalpana Sharma, Deepti Parmar
DOI:10.4103/ASJO.ASJO_36_17  
The metastasis to the eye in a patient of carcinoma of the cervix is rare. A case of carcinoma cervix in a 56-year-old female is described who presented with full chamber pseudohypopyon and deep vascularization in inferior quadrant of the cornea in the left eye. Magnetic resonance imaging revealed features suggestive of ocular metastasis in the anterior part of the uveal tract. Diagnosis was confirmed on cytology which showed features of squamous cell carcinoma. A high level of clinical suspicion in advanced cases of malignancies will help in early detection of ocular metastasis with unusual presentations.
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Insulinoma presenting as complex partial seizures p. 151
Brahmanandam Lingudu, Vivekanand Bongi, Mythili Ayyagari, Subrahmanyam Kandregula Appala Venkata
DOI:10.4103/ASJO.ASJO_65_15  
We describe a 42-year-old male patient who presented with recurrent left focal seizures with altered sensorium refractory to polytherapy with antiepileptic drugs and recurrent hypoglycemic episodes. Whipple's triad was documented. Insulin, C-peptide levels were elevated, and insulin-glucose ratio was more than 0.3 confirming the endogenous hyperinsulinism. Magnetic resonance imaging (MRI) abdomen revealed mass in the tail and distal body of the pancreas. Interictal electroencephalography showed generalized slow wave activity in delta range. MRI brain was normal. Excision of tumor was done. Histopathology confirmed the insulinoma. The patient had no recurrence of seizures during follow-up.
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A challenging case of anaplastic large-cell lymphoma with primary bony presentation p. 155
Manasi Mundada, Faiq Ahmed, A Santa
DOI:10.4103/ASJO.ASJO_122_16  
Anaplastic large-cell lymphoma (ALCL) is a distinct type of T-cell lymphoma showing varied clinicopathological features. The clinical entities identified are systemic and primary cutaneous types. ALK+ ALCL are more common in childhood with predominant nodal presentation. Extranodal involvement is commonly seen in the skin, bones, soft tissue, lung, liver, etc., Here, we present an intriguing case of ALK+ ALCL in an adult patient primarily presenting as multiple bony lytic lesions.
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