High-dose chemotherapy followed by autologous stem cell transplant for multiple myeloma: Predictors of long-term outcome

Background & objectives: Survival of patients with multiple myeloma (MM) has improved in the past two decades following use of novel agents and autologous stem cell transplantation. To determine predictors of long-term outcome, data of MM patients who underwent autologous stem cell transplantation (ASCT) at a tertiary care centre in north India were retrospectively analyzed. Methods: Between 1995 and 2016, 349 MM patients underwent ASCT. Patients' median age was 52 yr, ranging from 29 to 68 yr, 68.2 per cent were males. Thirty three per cent patients had international staging system (ISS) Stage III and 68.5 per cent had received novel agents-based induction. High-dose melphalan (200 mg/m2) was used for conditioning; patients with renal insufficiency (estimated glomerular filtration rate <40 ml/min) received melphalan 140-150 mg/m2. Results: Post-transplant, 317 of 349 (90.8%) patients responded; complete [complete response (CR)] ?213 (61%)], very good partial response (VGPR) ?62 (17.8%) and PR in 42 (12%)]. Induction with novel agents, pre-transplant chemosensitive disease, transplant in first remission and serum albumin (?3.5 g/dl) were predictors of significant response. At a median follow up of 73 months, median overall survival (OS) was 90 months [95% confidence interval (CI) 70.8-109.2], and progression-free survival (PFS) was 41 months (95% CI 33.0-49.0). On multivariate analysis, achievement of CR post-transplant, transplant in first remission, ISS Stages I and II (vs. III), absence of extramedullary disease and serum albumin ?3.5 g/dl were predictors of prolonged OS. For PFS, achievement of post-transplant CR and transplant in first remission were predictors of superior outcome. Interpretation & conclusions: Treatment with novel agents, achievement of complete remission post-transplant, ISS Stages I and II, absence of extramedullary disease and transplant in first remission were predictors of long-term survival for patients with MM.

Role of computed tomography (CT) scan in staging of cervical carcinoma.

Background & objectives: Staging of cervical carcinoma is done clinically using International Federation of obstetrics and Gynecology (FIGO) guidelines. It is based on physical examination findings and also includes results of biopsy, endoscopy and conventional radiological tests like chest radiograph, intravenous urography and barium enema. These conventional radiological investigations have largely been replaced by computed tomography (CT) and magnetic resonance imaging (MRI) at present. FIGOo staging system does not consider CT and MRI mandatory; however, use of these modalities are encouraged. tThis prospective study was conducted to determine the role of CT in staging work up in women diagnosed with cervical carcinoma. Methods: Fifty three women diagnosed with cervical carcinoma were evaluated with contrast enhanced CT scan of abdomen and pelvis. CT scan images were especially evaluated to determine tumour size, invasion of parmetrium, pelvic walls, rectum, urinary bladder and ureters, pelvic or retroperitoneal lymphadenopathy and distant metastases. CT findings were associated with clinical findings and staging, including findings from cystoscopy and sigmoidoscopy. Results: There was a poor agreement between clinical and CT staging of cervical carcinoma. Primary tumour was demonstrated on CT in 36 (70%) of 53 patients. CT underestimated the parametrial, vaginal and pelvic wall invasion when compared with physical examination. CT overestimated the urinary bladder and rectal invasion when compared with cysto-sigmoidoscopy, however, CT had 100 per cent negative predictive value (NPV) to exclude bladder and rectal involvement. CT detection of lymph node enlargement and lung metastases influenced the management. Interpretation & conclusions: Our findings show that CT scan does not reliably correlate with clinical FIGOo staging of cervical cancer. However, it can detect urinary obstruction as well as nodal or distant metastases and thus improves the clinical FIGOo staging

Role of 18F-fluorodeoxy glucose PET-CT in asymptomatic epithelial ovarian cancer with rising serum CA-125: A pilot study.

Background. We evaluated the role of 18F-fluorodeoxy glucose (FDG) PET-CT scan in the diagnosis of early relapse in patients with epithelial ovarian cancer (EOC) who were asymptomatic but had a rising serum CA-125 level. Methods. Between May 2006 and July 2008, 16 patients with advanced EOC (stages III and IV) who had achieved complete response after cytoreductive surgery and platinumbased chemotherapy were included. These patients were asymptomatic but had a rising serum CA-125 level with normal physical examination and contrast-enhanced CT scan of the abdomen and pelvis. Patients were evaluated with 18F-FDG PET-CT scan. Written informed consent was taken. Patients with a positive PET-CT scan were advised ultrasoundguided fine-needle aspiration cytology (FNAC) from the area showing increased uptake. Patients in whom FNAC was negative or inconclusive or those with negative PET-CT scan were followed up closely for the next 6 months with repeat clinical evaluation and CT scan. Results. Fifteen patients (15/16) had a positive PET-CT scan. In 9 patients the positive PET lesion was confirmed on FNAC, while in 5 patients this was confirmed on follow-up CT scan after 6 months. One patient who had a single positive lesion in the pelvis on PET-CT was initially considered falsepositive because a follow-up CT scan at 6 months did not show the lesion. However, on regular follow-up after 2 years, she was detected to have an isolated lesion in the PET-positive area which was confirmed on secondary cytoreduction. This patient was considered as true-positive in the current analysis. One patient, who had a negative PET-CT scan and a negative CT scan at 6 months’ follow-up was considered true-negative. The sensitivity and specificity of PET-CT scan was 100%. We could confirm positivity on histopathology/FNAC in 10 of the 15 (66.7%) true-positive cases. Conclusion. 18F-FDG PET-CT scan is a sensitive and specific technique for early diagnosis of relapse in asymptomatic EOC patients with rising CA-125. However, its role in the management of recurrent ovarian cancers needs further evaluation.

Radiation dose escalation by percutaneous interstitial brachytherapy in locally advanced non-small cell lung cancer.

Management of locally advanced non-small cell lung cancer is associated with a poor overall survival using concurrent chemoradiotherapy. Therefore, newer approaches to treatment which enable dose escalation are warranted. Interstitial brachytherapy in lung is a new emerging concept with many distinct advantages. We report here a case of locally advanced non-small cell lung cancer with residual disease after conventional treatment. The patient was successfully treated using percutaneous interstitial brachytherapy and is disease-free at 18-month follow-up.

Radiofrequency ablation of hepatic metastasis: results of treatment in forty patients.

AIM: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. MATERIALS AND METHODS: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. RESULTS: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. CONCLUSIONS: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size.

Mature ovarian teratoma with gliomatosis peritonei--a case report.

Gliomatosis peritonei (GP), a rare condition related to ovarian teratomas, is characterized by miliary implants of mature glial tissues on the peritoneum or omentum. We report herein a case of mature teratoma of the ovary with GP with imaging features and pathological correlation.

Germ cell tumours of the testis: clinical features, treatment outcome and prognostic factors.

BACKGROUND: The prognosis of patients with germ cell tumours of the testis has Improved over the past two decades following cisplatinum-based chemotherapy. Currently, staging and risk assessment of the disease is crucial in order to provide curative therapy for patients with poor risk features and not over-treat good risk patients. METHODS: We reviewed the case records of 71 men diagnosed to have germ cell tumours between January 1993 and October 1999. Their clinical characteristics, staging, treatment outcome and prognostic factors for response and survival were analysed. RESULTS: The median age of the patients was 30 years (range: 3-65 years); 69% were in the third and fourth decades. Sixty-one patients (86%) had a primary testicular tumour while in 10 (14%) the tumour was extragonadal. Histopathologically, 53 patients (75%) had non-seminomatous germ cell tumours and 15 (21%) had a seminoma. Twenty-seven patients (62%) had evidence of metastatic disease at the time of diagnosis. On prognostication, non-seminomatous germ cell tumour patients could be divded into good, intemediate and poor prognostic groups comprising 41%, 17% and 40% of patients, respectively. All patients with a seminoma were in the good prognostic subgroup. Fifty-eight patients were evaluable for response. Overall, 91% of patients responded: complete response 71% and partial response 20%. Complete response rates were signiflcantly higher for the good risk (95%) compared to the intermediate (49%) and poor risk (47%) categories (p< 0.003). At a median follow up of 26 months, the 2-year overall and progression-free survival for all patients was 70% and 57%, respectively. The predictors for decreased overall and progression-free survival were age >35 years, presence of poor risk features and mediastinal primary disease. CONCLUSION: The outcome for germ cell tumours in men with good risk is excellent. A protocol consisting of bleomycin, etoposide and cisplatin is effective. Tailoring of chemotherapy In good risk patients to minimize toxicity and Improving results in poor risk patients are areas that need further work.

Leiomyosarcoma of pancreas: imaging features.

Leiomysosarcoma of the pancreas is rare. Radiological findings of four patients with this condition were reviewed. CT scan appearances were those of a predominantly homogenous, large, solid, enhancing mass with few areas of necrosis. A cystic appearance with thickened and nodular enhancing walls was seen in one case. A constellation of imaging findings including large size at presentation, greater vascular enhancement and absence of biliary dilatation should suggest leiomyosarcoma.