Targeted Therapy Management in NSCLC Patients Using Cytology: Experience from a Tertiary Care Cancer Center.

BACKGROUND: Although biopsy is the gold standard for diagnosis, cytological material has often been used to assist in making a pathologic diagnosis as well as for molecular testing in certain cancers such as in the lung, cervix, and head/neck. OBJECTIVE: Our objective is to share experience from our institution in the use of cytological material in screening for epidermal growth factor receptor (EGFR) mutations in a subset of patients with non-small cell lung cancer (NSCLC). METHODS: Fine needle aspirates, pleural effusion, cell blocks of 223 NSCLC patients, where cytology suggested malignancy were screened for EGFR mutation in exons 18-21 using Scorpion(®) ARMS real-time polymerase chain reaction (PCR) technology. RESULTS: Overall, EGFR mutation was seen in 43.5 % of study samples. Deletions were highest in exon 19 (27.2 %), followed by exon 21 (15.5 %), exon 18 (5.3 %), and exon 20 (1.9 %). Chi-squared analysis revealed a significant correlation for mutation status in women compared with men (χ (2) = 5.88, p = 0.02), with exon 19 mutation predominating (χ (2) = 5.66, p = 0.02). CONCLUSION: Our results demonstrate the successful use of cytology material for molecular testing in a subset of NSCLC patients to direct their treatment.

Clinical and epidemiological study of EGFR mutations and EML4-ALK fusion genes among Indian patients with adenocarcinoma of the lung.

BACKGROUND: Mutation in the tyrosine kinase domain of epidermal growth factor receptor (EGFR) is a common feature observed in lung adenocarcinoma. A fusion gene between echinoderm microtubule-associated protein-like 4 (EML4) and the intracellular domain of anaplastic lymphoma kinase (ALK), named EML4-ALK, has been identified in a subset of non-small-cell lung cancer (NSCLC) tumors. The objective of this study was to determine the prevalence of EGFR mutations and EML4-ALK fusions in Indian patients with NSCLC (adenocarcinoma) as well as evaluate their clinical characteristics. PATIENTS AND METHODS: Patients with NSCLC, adenocarcinoma histology, whose tumors had been tested for EGFR mutational status, were considered for this study. ALK gene rearrangement was detected by fluorescence in situ hybridization using the Vysis ALK Break Apart Rearrangement Probe Kit. ALK mutation was tested in samples that were negative for EGFR mutation. RESULTS: A total of 500 NSCLC adenocarcinoma patients were enrolled across six centers. There were 337 (67.4%) men and 163 (32.6%) women with a median age of 58 years. One hundred and sixty-four (32.8%) blocks were positive for EGFR mutations, whereas 336 (67.2%) were EGFR wild-type. Of the 336 EGFR-negative blocks, EML4-ALK fusion gene was present in 15 (4.5%) patients, whereas 321 (95.5%) tumors were EML4-ALK negative. The overall incidence of EML4-ALK fusion gene was 3% (15/500). CONCLUSION: The incidence of EGFR mutations (33%) in this Indian population is close to the reported incidence in Asian patients. EML4-ALK gene fusions are present in lung adenocarcinomas from Indian patients, and the 3% incidence of EML4-ALK gene fusion in EGFR mutation-negative cases is similar to what has been observed in other Western and Asian populations. The mutual exclusivity of EML4-ALK and EGFR mutations suggests implementation of biomarker testing for tumors harboring ALK rearrangements in order to identify patients that can benefit from newer targeted therapies.

Genomic profiling in a homogeneous molecular subtype of non-small cell lung cancer: An effort to explore new drug targets.

BACKGROUND: Patients' who are positive for kinase domain activating mutations in epidermal growth factor receptor (EGFR) gene, constitute 30-40% of non-small cell lung cancer (NSCLC), and are suitable candidates for Tyrosine Kinase Inhibitor based targeted/personalized therapy. In EGFR non-mutated subset, 8-10% that show molecular abnormalities such as EML4-ALK, ROS1-ALK, KIP4-ALK, may also derive the benefit of targeted therapy. However, 40% of NSCLC belong to a grey zone of tumours that are negative for the clinically approved biomarkers for personalized therapy. This pilot study aims to identify and classify molecular subtypes of this group to address the un-met need for new drug targets in this category. Here we screened for known/novel oncogenic driver mutations using a 46 gene Ampliseq Panel V1.0 that includes Ser/Thr/Tyr kinases, transcription factors and tumor suppressors. METHODS: NSCLC with tumor burden of at least 40% on histopathology were screened for 29 somatic mutations in the EGFR kinase domain by real-time polymerase chain reaction methods. 20 cases which were EGFR non-mutated for TK domain mutations were included in this study. DNA Quality was verified from each of the 20 cases by fluorimeter, pooled and subjected to targeted re-sequencing in the Ion Torrent platform. Torrent Suite software was used for next generation sequencing raw data processing and variant calling. RESULTS: The clinical relevance and pathological role of all the mutations/variants that include SNPs and Indels was assessed using polyphen-2/SIFT/PROVEAN/mutation assessor structure function prediction programs. There were 10 pathogenic mutations in six different oncogenes for which annotation was available in the COSMIC database; C420R mutation in PIK3CA, Q472H mutation in vascular endothelial growth factor receptor 2 (VEGFR2) (KDR), C630W and C634R in RET, K367M mutation in fibroblast growth factor receptor 2 (FGFR2), G12C in KRAS and 4 pathogenic mutations in TP53 in the DNA binding domain (E285K, R213L, R175H, V173G). CONCLUSION: Results suggest, a potential role for PIK3CA, VEGFR2, RET and FGFR2 as therapeutic targets in EGFR non-mutated NSCLC that requires further clinical validation.

Prevalence of KRAS mutations in metastatic colorectal cancer: A retrospective observational study from India.

BACKGROUND: One of the genetic alterations implicated in tumor progression in colorectal cancers (CRCs) are abnormalities in Kristen Rat Sarcoma (KRAS) gene. Evaluation of KRAS mutation status is an important prognostic factor and has predictive value in deciding first line therapy based on monoclonal antibodies such as Cetuximab and Panitumumab in metastatic CRCs. MATERIALS AND METHODS: In this retrospective study, we analyzed 7 different somatic mutations in Exon 2 of KRAS gene in 299 unselected incidental CRC patients who visited the hospital for clinical management during the period 2009-2013. Most of the tumors were primarily originating from colon and rectum; nevertheless, there were a few from rectosigmoid, sigmoid, ceacum and anal canal in the study group. Genomic DNA extracted from paraffin embedded tumor tissues was screened for 7 point mutations located in Codons 12 and 13 of KRAS gene, using Scorpions amplified refractory mutation system real time polymerase chain reaction technology. Statistical analysis was performed to assess bivariate relationship between different variables that includes: mutation status, mutation type, tumor location, tumor morphology, age and sex. RESULTS: Prevalence of mutation in Codons 12 and 13 was 42.8% in the study group. Well-differentiated tumors had significantly more mutation positivity than moderately and poorly differentiated tumors (P = 0.001). 92% of the mutations were from Codon 12 and 8% in Codon 13. Glycine to Arginine was relatively more common in rectosigmoid followed by ceacum, while Glycine to Alanine mutation was relatively more prevalent in sigmoid, followed by rectum and rectosigmoid. CONCLUSION: The results suggest a prevalence of KRAS mutation at 42.8% in Indian population indicating that this testing is very crucial for targeted therapy management in metastatic CRC in India. Further analysis on mutation status of other homologues such as NRAS and downstream partner, v-raf murine sarcoma viral oncogene homolog B1, would add value to understanding the role of anti-epidermal growth factor receptor therapy in CRC management.

Epidermal growth factor receptor mutation in non-small-cell lung carcinomas: a retrospective analysis of 1036 lung cancer specimens from a network of tertiary cancer care centers in India.

BACKGROUND: Epidermal growth factor receptor (EGFR) mutation plays a vital role in the prognosis of patients with lung cancer. However, there is a dearth of studies on EGFR mutation in Indian population. In this retrospective study conducted at a network of tertiary cancer care centers across India, we evaluated the proportion of EGFR mutation in patients with non-small-cell lung carcinomas (NSCLC). MATERIALS AND METHODS: A total of 1036 cases of non-small lung cancer were assessed for EGFR mutation status using Scorpion amplified refractory mutation system real time polymerase chain reaction method from fine needle aspiration cytology core biopsy, pleural fluid and cell blocks. For a few cases, macro dissection of tumor from H and E slides was also performed for EGFR analysis. EGFR Status was assessed for the most commonly known driver mutations in Exons 18, 19, 20 and 21, which contributes to a total of 29 somatic mutations including the resistance mutation T790M. RESULTS: Around 39% of the cohort was female and 61% were male. Mutation was positive in 40.3% and negative (wild type) in 59.7%. There was 1.8% mutation in exon 18, 24.6% in exon 19, 1.6% in exon 20 and 12.8% in exon 21. 38.2% had a mutation in a single site and 1.1% had a mutation in two sites. Overall mutation was significant in females (50.5% vs. 33.9%) compared with males (χ2 = 28.3, P < 0.001). Mutation was significant in exon 21 (16.8% vs. 10.3%, χ2 = 9.44, P = 0.002) and exon 19 (30.7% vs. 20.7%, χ2 = 13.2, P < 0.001) in females compared with males. CONCLUSION: EGFR is expressed differentially/mutated in patients with NSCLC. Further studies to unravel the predictors for acquired genetic alterations of EGFR are needed.

Prevalence and pattern of substance abuse at bandardewa, a border area of assam and arunachal pradesh.

A total of 312 persons aged 10 years and above were interviewed to collect information about their habits of taking tobacco, alcohol and other substances. The study reveals that 40.4% of the respondents used tobacco irrespective of their using pattern, with significant difference between sexes (p< 0.001). Among tobacco users 58.2% were only tobacco chewers. 26.3% were smokers and 15% of them were practicing both the modes. 61.4% among housewives were tobacco users. Prevalence of alcohol use was 36.5% among the respondents. Alcohol use among males (39.5%) was slightly higher than females (32.6%). A significant association of alcohol users (p< 0.01) was observed with level of educational status. 3.4% of the study population were found to be habituated with substance abuse other than tobacco and alcohol. Percentage of injecting drug users was found to be 1.28%. A very small number (0.64%) was also found to be addicted to petrol inhalation.

Prevalence of communicable disease among restaurant workers along a highway in Assam, India.

105 workers of 29 roadside restaurants along a highway in Assam were interviewed for their habits, educational status and were examined for their hygienic status and presence of communicable diseases (STDs,TB etc). Most of them were young, males with 40% literacy; more than half were unmarried. About 30% of them were alcoholic and smokers and 2.9% were addicted to cannabis. The hygienic conditions of the workers were poor. More than one third had sexual contact with multiple sex partners or commercial sex workers and 2% were engaged in homosexual activity. Most of them did not use condom. 25.7% of them had genital lesions suggestive of sexually transmitted disease, 11.8% showed gram negative diplococci in urethral smears and 5.1% were VDRL reactive. Skin infections followed by gastrointestinal disorders and respiratory tract infections were other prevalent problems. 70.6% were positive for intestinal parasites and 22.2% were sputum positive for acid fast bacilli. However all the collected blood samples were negative for HIV.

Fine needle aspiration cytology of hepatocellular carcinoma.

Fine needle aspiration cytology (FNAC) is an extremely useful technique in the evaluation of hepatic masses. This study was undertaken with the aim of describing the morphological spectrum seen in fine needle aspirates from hepatocellular carcinoma (HCC) seen in our patients hailing from South India. Thirty two cases of HCC were studied. Trabacular pattern covered by endothelium was the most common. Pseudoglandular, spindle cell and dispersed patterns were also seen. Individual tumour cells were generally reminiscent of hepatocytes, and had a prominent nucleolus. The presence of intranuclear and intracytoplasmic inclusions were notable features. FNA cytology in HCC is sufficiently distinctive to form an invaluable tool in the diagnosis of this malignancy.

Diagnosis of clival chordoma by fine needle aspiration of an oropharyngeal mass. A case report.

A sphenooccipital chordoma presenting as a large nasopharyngeal mass extending into the oropharynx was diagnosed by transoral fine needle aspiration biopsy (FNAB) and confirmed by subsequent histologic studies. The cytologic features of chordoma are presented, and the diagnostic utility of FNAB in evaluating similar lesions in the head and neck region is discussed.

Hemangiopericytoma of bone--a case report.

A case of low grade hemangiopericytoma of three years duration occurring in the upper end of the femur of a 70 year old man is described. Radiologically, the upper third of the right femur showed a destructive expansile osteolytic lesion with soft tissue extension. The tumour was partially encapsulated. Mitoses were 0-1 per 10 high power fields, suggesting the low grade malignant nature of the lesion. It is felt that all hemangiopericytomas occurring in bone should be considered biologically malignant.

Fine needle aspiration cytology of chondroblastoma and chondromyxoid fibroma. A report of two cases.

The fine needle aspiration cytology in two cases of chondroblastoma and chondromyxoid fibroma are described. The diagnosis of chondroblastoma was made on a recurrent tumor of which the histopathology was known, whereas chondromyxoid fibroma was diagnosed initially on fine needle aspiration cytology. The radiologic appearances and differential diagnoses of these chondroid neoplasms are discussed.

Adult paratesticular sarcomas: a report of eight cases.

Eight adult paratesticular sarcomas seen at a Regional Cancer Centre over a 7-year period are described. There were three cases of rhabdomyosarcoma (RMS), three cases of leiomyosarcoma (LMS), and two cases of liposarcoma (LS). The RMS occurred in a younger age group (3rd decade) than the LMS and LS (6th and 7th decades). Most of our patients presented with advanced disease after orchiectomy at other hospitals, three with recurrent or residual disease and four with metastasis. The single patient with RMS who received intensive adjuvant therapy is free of disease at 84 months in spite of the advanced stage at presentation. All three patients with LMS had an unfavourable clinical course. Both the patients with LS had well differentiated (WD) tumours and presented with recurrences, one over several years, following initial local excisions. The necessity for early adequate surgical and adjuvant therapy and the need for a uniform treatment policy are discussed.

Sclerosing stromal tumour of the ovary.

Sclerosing stromal tumour (SST) of the ovary is a rare entity. It is a benign neoplasm which forms a distinct subgroup separate from the other ovarian stromal tumours, including thecomafibromas, by virtue of its unique histology. One such tumour in a 25-year old female is reported.

Fine needle aspiration cytology of Wilms' tumor. A study of 17 cases.

The cytologic features of 17 cases of Wilms' tumor are described. All three elements identifiable histologically are usually present in the fine needle aspiration smears. In our cases the blastemal component predominated, with varying degrees of epithelial and stromal differentiation, which was identifiable in the form of skeletal and smooth muscle. Early epithelial differentiation was identified as rosette-like and gland-like structures, groups of cells with peripheral palisading and spherical, tightly bound clusters of cells. More-differentiated epithelial cells were seen individually, in small, loose clusters, in sheets with a honeycomb appearance and as elongated tubules. Coarse, magenta, granular material was seen in the background of the smears in the majority of our cases. Fine needle aspiration under ultrasound guidance to accurately localize the tumor and a posterior approach to avoid peritoneal spillage are recommended. In difficult cases, a cell block of the aspirated material is a useful adjunct.

Salivary duct carcinoma.

Salivary duct carcinoma is an uncommon malignant tumor that occurs mainly in the parotid gland of elderly men. The 11 cases of salivary duct carcinoma which are included in this study occurred in older men (mean age 56 years) and were located in the parotid (7), submandibular salivary gland (2), and the minor salivary glands in the maxilla (2). The maximum tumor dimension ranged from 3 to 9 cm. Microscopically, all had infiltrating margins, with circumscribed groups of epithelial cells arranged in various patterns; the invasive component was embedded in a desmoplastic stroma. Perineural invasion and lymph node metastasis were noted in seven and three cases, respectively, at the time of initial surgery. Radical surgery was offered to ten patients and postoperative radiotherapy to nine patients. Salivary duct carcinoma appears to be an aggressive tumor with distinctive histological features, which has not been described in the minor salivary glands of the maxilla to date. The clinicopathologic features of these tumors are presented, with a review of the literature.

Fine needle aspiration biopsy cytology of chondrosarcoma.

The cytomorphological appearances of bone and soft tissue tumours, when combined with radiology and clinical presentation, can lead to a positive diagnosis in the majority of cases. Our experience with fine needle aspiration biopsy of 13 cases of chondrosarcoma, encountered over a four year period is presented, in correlation with their radiological appearances. It is concluded that. FNAB is a valuable pre-operative tool in characterising chondroid neoplasms in soft tissue and bone.

Parapharyngeal ganglioneuroma. Report of a case diagnosed by fine needle aspiration.

A case of ganglioneuroma presenting in a parapharyngeal location in a 4-year-old girl was subjected to fine needle aspiration cytology. A preoperative diagnosis of ganglioneuroma was subsequently confirmed on histopathologic examination. Only a few reports on the cytologic features of this tumor exist. The importance of considering this diagnosis for a tumor at an unusual site and in an uncommon age group is stressed.