Treatment of patients with metastatic pancreatic cancer: Experience from a tertiary Indian cancer center.

BACKGROUND: The aim of this study was to look at the outcome of patients with metastatic pancreatic cancer treated at a tertiary cancer center in India. PATIENTS AND METHODS: A total of 101 patients with locally advanced and metastatic pancreatic cancer diagnosed between May 2012 and July 2013 were identified from a prospectively maintained database at the tertiary cancer center. Overall survival (OS) was computed using the Kaplan–Meir product limit method and compared across groups using the log‑rank statistics. Cox proportional hazards model, adjusted for a number of patient and tumor characteristics, was then used to determine factors prognostic for OS. RESULTS: Median age at diagnosis was 55 years (range: 21–81 years). 57.4% (n = 58) of patients were male, 22% (n = 22) had performance status (PS) of <2 at diagnosis and 89% received first‑line chemotherapy, while the rest received best supportive care. For the whole cohort, 6 month and 1‑year OS was 57% (95% confidence interval [CI]: 46–66%) and 47% (95% CI: 35–57%), respectively. In a multivariable model, PS <2 and oligometastatic disease were associated with a significantly decreased risk of death. CONCLUSION: Results from our analysis indicate that the prognostic outcome among Indian patients with metastatic pancreatic cancer is poor with survival outcomes similar to those reported in North America and Europe.

Sunitinib in patients with imatinib‑resistant gastrointestinal stromal tumor: A single center experience.

AIM: The outcome of patients with advanced gastrointestinal stromal tumor (GIST) has improved with the use of imatinib. Despite high response rates with this drug resistance eventually develops in nearly all patients. We present an analysis of prospectively collected data on sunitinib efficacy and safety in patients with imatinib‑resistant GIST. SUBJECTS AND METHODS: Between November 2006 and October 2007, patients with GIST were accrued in an approved sunitinib patient access protocol. Key eligibility criteria included tumor resistance to imatinib and/or patient intolerance to this drug. Patients received sunitinib at a starting dose of 50 mg once daily for 4 weeks in a 6 week cycle, with standardized dose modification titrated to toxicity. Patients were continued on sunitinib until disease progression or unacceptable toxicity. The endpoints were safety, overall survival (OS) and objective response rate (ORR). RESULTS: Fifteen patients, all of whom had imatinib resistance and none intolerance, with median age of 48 (26–69) years, were treated on the protocol. The most common sites of primary disease were small intestine (40%), stomach (26.7%) and retroperitoneal (26.7%). A median of 10 (1–47) cycles of sunitinib were delivered, 9 (60%) patients required dose reductions due to toxicity whereas dose delay of > 2 weeks was required in only one (6.7%) patient. There were no toxicity‑related drug discontinuations. Hypothyroidism (n = 4; 26.7%) and hand‑foot syndrome (n = 3; 20%) were the most common toxicities. There were no complete and 4 (26.7%) partial responses while prolonged disease stability was seen in 8 (53.3%) patients. At a median follow‑up of 81 months in surviving patients, the median progression‑free and overall survivals were 15.5 and 18.7 months, respectively. CONCLUSIONS: Sunitinib appears to be an effective and well‑tolerated treatment for Indian patients with imatinib‑resistant GIST with outcomes similar to that reported previously. Adverse effects can be reasonably well managed using a dose modification strategy.

Are we achieving the benchmark of retrieving 12 lymph nodes in colorectal carcinoma specimens? Experience from a tertiary referral center in India and review of literature.

Introduction: The number of lymph nodes (LNs) retrieved from a specimen of colorectal carcinoma may vary. Factors that can possibly affect LN yield are age of the patient, obesity, location of the tumor, neoadjuvant therapy, surgical technique and pathologist's handling of the specimen. Aim: The aim of our study is to look at lymph node retrieval from colorectal cancer (CRC) specimens in our hands and review the literature. Materials and Methods: From May 2010 to January 2011, a total of 170 colorectal carcinoma cases were operated in our institute. Type of the surgeries, lymph node yield was looked at. Results: There were 103 (60.6%) males and 67 (39.4%) females. The commonest age group was 50-59 years (30.6%). The surgeries included 107 surgeries for rectal carcinoma (63%) and 63 surgeries for colonic carcinoma (37%). Sixty six (38.8%) cases had received preoperative chemoradiotherapy, whereas 104 (61.2%) cases were without adjuvant therapy. The total lymph node positivity (metastatic disease) was 44.7% .The overall mean lymph node yield was 12.68 (range 0-63; median 11). The mean lymph node harvest in the age group < 39 was 15.76 whereas, the lymph node harvest in the group more than 39 years old was 11.90. ( statistically significant; P=0.03). The mean lymph node yield from specimens of rectal cancers (10.30) was lower than the mean lymph node yield from specimens for colonic cancers (16.71);( statistically significant, P<0.01). There was also statistically significant difference between the mean LN yield in chemoradionaiive cases (14.63) and in the cases where neoadjuvant therapy was received, (9.59); P<0.01. Conclusion: Pathologist while assessing a specimen of CRC should aim to retrieve a minimum of 12 LN. Surgical expertise and diligence of the pathologists remain two main alterable factors that can improve this yield. Neoadjuvant or preoperative radiotherapy can yield in less number of nodes.

Preoperative assessment and optimization in periampullary and pancreatic cancer.

Perioperative management of pancreatic and periampullary cancer poses a considerable challenge to the pancreatic surgeon, anesthesiologist, and the intensive care team. The preoperative surgical evaluation of a pancreatic lesion aims to define the nature of the lesion (malignant or benign), stage the tumor, and to determine resectability or other non-surgical treatment options. Patients are often elderly and may have significant comorbidities and malnutrition. Obstructive jaundice may lead to coagulopathy, infection, renal dysfunction, and adverse outcomes. Routine preoperative biliary drainage can result in higher complication rates, and metal stents may be preferred over plastic stents in selected patients with resectable disease. Judicious use of antibiotics and maintaining fluid volume preoperatively can reduce the incidence of infection and renal dysfunction, respectively. Perioperative fluid therapy with hemodynamic optimization using minimally invasive monitoring may help improve outcomes. Careful patient selection, appropriate preoperative evaluation and optimization can greatly contribute to a favorable outcome after major pancreatic resections.

Pancreatic carcinogenesis: The impact of chronic pancreatitis and its clinical relevance.

Pancreatic cancer is a devastating disease with a dismal prognosis and early detection remains a challenge. On the background that inflammation is one of the key steps in the development of cancer, it is natural that chronic pancreatitis is considered as one of the etiological factors for the development of pancreatic cancer. However, the process of pancreatic carcinogenesis is a multifactorial phenomenon rather than a process that evolves solely via inflammation. This review attempts to put into perspective the association between different etiological forms of chronic pancreatitis and pancreatic cancer, and the diverse mechanisms operational in the process of pancreatic carcinogenesis. Furthermore, the clinical relevance of the current understanding of the relationship between chronic pancreatitis and pancreatic cancer, especially with regard to the pancreatic head mass of uncertain etiology, is discussed in this review.

Pulmonary cryptosporidiosis in HIV negative, immunocompromised host.

Cryptosporidia are intestinal spore forming protozoa, which cause intracellular infections, predominantly in the epithelial cells of the intestine. Extra-intestinal infections with Cryptosporidium parvum have been rarely reported. However, a few reports of pulmonary cryptosporidiosis in HIV/AIDS cases have been mentioned in literature. In immunocompromised individuals who do not have HIV-related disease, Cryptosporidiosis has been rarely reported. We present a case of respiratory infection caused by C. parvum. The patient was a 10-year-old child with nephrotic syndrome and was receiving corticosteroids for 6 months. The child had history of low-grade fever, breathlessness and cough with expectoration of 3 months duration. The patient was nonreactive for HIV, and there was no evidence of primary immunodeficiency. Major serum immunoglobulins (IgG, IgA, and IgM) were in normal range. Simultaneous gastrointestinal involvement with C. parvum was observed.

Respiratory tract infection due to Arcanobacterium haemolyticum--a case report.

A case of respiratory tract infection due to Arcanobacterium haemolyticum is reported. A female of 26 years presented with cough with expectoration and fever off and on for a duration of six weeks. Mycobacterium tuberculosis and Arcanobacterium haemolyticum were isolated. Arcanobacterium haemolyticum was isolated on three separate occasions.

Breast metastases of gastric signet ring cell carcinoma: a differential diagnosis with primary breast signet ring cell carcinoma.

Metastatic deposits within the breast may be difficult to distinguish from primary breast carcinoma. Radiological features and immunohistochemistry especially for steroid hormone receptors and expression of gross cystic disease fluid protein may be helpful in differentiating these two conditions. In this report, we present a case of signet ring cell stomach cancer with metastasis to the breast and discuss the differential diagnostic options.

Chest wall metastases from unknown primary hepatocellular carcinoma.

Metastases of hepatocellular carcinoma (HCC) to the bones are common but bone metastases of hepatocellular carcinoma in the presence of a normal liver are an uncommon entity. A 50-year-old male patient presented with a rapidly growing tumour on the sternum. Biopsy of the lesion showed metastatic sternal tumour from a primary hepatocellular carcinoma. Radiological evaluation however, failed to detect a primary lesion in the liver. Bone metastases of hepatocellular carcinoma localized to the chest wall in the presence of a normal liver are scarcely reported as anecdotal case reports in the literature.

Virulence factors in uropathogenic E. coli.

Escherichia coli isolates from urinary tract infections often exhibit characters different from those isolated from normal faecal samples. Adherence to uroepithelial cells, nature of lipopolysaccharide O antigen and mannose resistant haemagglutination of human erythrocytes are some of the important virulence factors proposed in the pathogenesis of urinary tract infections caused by E. coli. In the present study a total of 100 strains of E. coli isolated from symptomatic cases of urinary tract infections (with significant bacteriuria) were studied for these properties. Faecal isolates of E. coli from adult healthy individuals were also studied as controls. As many as 58 uropathogenic strains showed high affinity for attachment to uroepithelial cells while 28 strains showed adherence at moderate degree. Agglutination of human erythrocytes was induced by as many as 70 uropathogenic strains while in 32 strains haemagglutination was not affected by D-mannose. In control group, adherence was observed in eight strains while 28 strains were haemagglutinating. Of these 28 strains, D-mannose resistant haemagglutination was observed in only one faecal strain. In uropathogenic group O4 was isolated with maximum frequency (12%) followed by O101, O135 and O6.

Dehydrational crisis from severe diarrhoea and risk of age-related cataract.

A group matched hospital based case-control study of 463 cases and equal number of controls was carried out at Government Medical College and Hospital, Nagpur to evaluate role of severe dehydrational crisis in age-related cataract development. The overall relative risk of age related cataract in relation to dehydrational crisis from severe diarrhoea was estimated to be 3.10 (2.28-4.20). The overall estimates of attributable risk per cent and population attributable risk per cent were calculated to be 0.67 (0.56-0.76) and 0.26 (0.18-0.35) respectively. In conclusion this study identified significant role of dehydrational crisis from severe diarrhoea in cataractogenesis.

Effectiveness of Bacillus Calmette Guerin (BCG) vaccination in the prevention of childhood pulmonary tuberculosis: a case control study in Nagpur, India.

A hospital-based, pair matched, case control study was carried out to estimate the effectiveness of BCG vaccination in the prevention of childhood pulmonary tuberculosis. The study included 126 incident cases of pulmonary tuberculosis (diagnosed by WHO criteria) below/equal the age of 12 years. Each case was pair matched with one control for age, sex, socio-economic status. Controls were selected from subjects attending study hospital for conditions other than tuberculosis and leprosy. The significant protective association between BCG and childhood pulmonary tuberculosis was observed (OR = 0.39, 95% CI = 0.22, 0.68). The overall vaccine effectiveness was 61% (95% CI = 32%, 78%). BCG was nonsignificantly more effective in underfives, among males and in upper-middle socioeconomic strata. The overall prevented fraction was estimated to be 47.53% (95% CI = 21.41%, 67.25%). Results of this study thus demonstrated a moderate effectiveness of BCG vaccination in prevention of childhood pulmonary tuberculosis in a Central India population.

Risk factors and protective factors of pelvic inflammatory disease: a case-control study.

Risk factors and some protective factors for pelvic inflammatory disease (PID) in women were assessed in a case control study. Use of intrauterine device (OR = 3.98, p < 0.0001), sexual activity with multiple partners and younger age (ORs = 3.97, 1.9 and p = 0.0003, 0.0034, respectively), history of previous PID (OR = 4.08, p = 0.004) and history of minor gynecologic operation (OR = 3.07, p = 0.0158) were significant risk factors for PID. Pregnancy was a significant protective factor (OR = 0.25, p = .0074). Sterilisation had a significant protective effect (OR = 0.37, p = 0.0443) on multivariate analysis but not significant on univariate analysis. The results indicated that, almost half of the PID load on the population can be reduced by proper handling of four risk factors namely, use of IUD, sexual activity with multiple partners, history of previous PID and history of minor gynecologic operation (PARP = 0.2146, 0.1101, 0.0824 and 0.0794, respectively).

Effectiveness of Bacillus Calamette Guerin (BCG) vaccination against genital tuberculosis: a case-control study.

A hospital-based pair-matched case-control study was performed at Government Medical College Hospital, Nagpur, to estimate the effectiveness of Bacillus Calmette Guerin (BCG) vaccination against genital tuberculosis. The study included 48 cases of genital tuberculosis in the age group of 21-34 years and an equal number of controls, matched for age and socioeconomic status. The estimates of vaccine effectiveness and prevented fraction were higher for the subjects in the age group of 21-30 years and subjects from middle strata of socioeconomic class. The overall vaccine effectiveness and prevented fraction was estimated to be 75 (38.85-89.79) and 49.99 (17.46-74.55) per cent respectively. Results of this study thus indicate that BCG vaccination is effective against genital tuberculosis.

Study of suspected plague cases for isolation and identification of Yersinia pestis.

A total of 62 suspected patients of plague were investigated for evidence of Yersinia pestis, by blood culture, lymph node aspirate culture, sputum culture, animal inoculation and serology for f1 antibodies against f1 antigen of Yersinia pestis. None of the samples was positive by direct smear examination and culture for Yersinia pestis, as well as for serology. The non positivity of the cultures is discussed.

Effectiveness of bacillus of Calmette-Guerin (BCG) vaccination against tuberculous meningitis: a case-control study.

A hospital-based pair-matched case-control study was carried out at Government Medical College Hospital, Nagpur to estimate the effectiveness of bacillus of Calmette-Guerin (BCG) vaccination against tuberculous meningitis. The study included 92 cases of tuberculous meningitis in the age group of 0-12 years and equal number of controls, matched for age, sex and socio-economic status. The protective effectiveness and prevented fraction were higher for the subjects in the age group of 0-6 years, males and subjects from upper strata of socio-economic class. The overall vaccine effectiveness and prevented fraction were estimated to be 86.54% (70.38-93.88%) and 65.54% (39.22-80.64%) respectively. Results of this study thus indicated that BCG vaccination was highly effective against tuberculous meningitis and played significant role in its prevention, in this population.

Species distribution of clinical isolates of Staphylococci.

Species identification of 103 strains of staphylococci isolated from various clinical specimens revealed as many as eight species. S. aureus was the commonest isolate (57.28%) followed by S. epidermidis (17.47%). S. hominis (8.73%), S. saprophyticus (6.79%), S. intermedius, S. capitis and S. cohni (1.94% each) in decreasing order. They were mostly isolated from pus (41.74%) followed by urine (22.33%) and blood (18.44%) accordingly. Of the total isolates, 65 were coagulase positive while 38 isolates were coagulase negative. Phase typing of S. aureus strains revealed that 49 isolates were typable of which 17 isolates belonged to phase group III, 16 to phase group 1, 4 to group II and 3 belonged to group V while 9 strains could not be grouped. The antibiotic resistance pattern showed maximum resistance to penicillin (63.10%) while resistance was minimum with gentamycin (8.73%). Resistance to ampicillin (51.45%), cephazoline (51.45%), erythromycin (31.06+) and cloxacillin (18.44%) was low to moderate. The increasing recognition of pathogenic potential of various species of staphylococci and emergence of drug resistance amongst them denotes the need to adopt better laboratory procedures to identify and understand the diversity of staphylococci isolated from clinical material.