A case series of unusual presentations of Burkitt's lymphoma.

CONTEXT: Burkitt's lymphoma (BL) is one of the fastest growing malignancies. It is the most common subtype of Non-Hodgkin's lymphoma in childhood. It has three major subtypes - endemic, sporadic, and immunodeficiency-associated types. AIMS: This study aims to study the clinicomorphologic features of this disease entity and to find optimal imaging technique for such cases. SETTING AND DESIGN: A retrospective observational study in a tertiary care center of academic and research potential. SUBJECTS AND METHODS: We are presenting three unusual cases of sporadic type of BL who presented initially as localized right iliac fossa mass mimicking as acute appendicitis. Initially, localized presentation progressed to diffuse abdominal mass lesions causing intestinal obstruction. RESULTS: These cases had emphasized the importance of accurate diagnosis by the ultrasonography (USG) or computed tomography (CT) scan for early diagnosis so as to manage such cases simply by early appropriate medical treatment. CONCLUSION: In this article, we will discuss the clinical and imaging features of BL with the role of USG, CT scan and positron emission tomography/CT in the abdominopelvic imaging of pediatric patients.

Tolerance of Chemoradiation in Advanced Head and Neck Cancers: Comparison Between Inpatients and Outpatients.

Concurrent chemoradiation (CCRT) is the mainstay of treatment for majority of locally advanced head and neck carcinomas (LAHNC). Addition of chemotherapy to radiotherapy increases the probability of local control and improved disease-free survival but at the cost of acute and delayed toxicities. A retrospective observational study. To compare the tolerance of CCRT and its toxicity profile amongst two groups, first arm (Arm A) being outdoor patients and the second group (Arm B) was hospitalized patients of LAHNC in an oncology centre of a tertiary care hospital. A total of 100 patients were enrolled, 50 in each arm. Overall, the most common site was oropharynx, followed by larynx and hypopharynx. 38 patients in Arm A received full 6 cycles of weekly chemotherapy with Inj Cisplatin infusion. 39 of the hospitalized patients completed 6 cycles of weekly Cisplatin, 04 patients also received 3 weekly Cisplatin. Average duration of treatment was 49.18 days in arm A and 50.92 days in arm B. Incidence of Grade II onwards dysphagia was 48 and 45 (96 and 90%) in Arm A and Arm B respectively; Chi Square value-0.6 (Yate's corrected); P value-0.43. Grade III oral mucositis was seen in 14% patients in Arm A and 34% patients in Arm B. 3 patients (6%) in Arm A and 14 patients (28%) in Arm B has Grade II and III hematological toxicities and nephrological toxicities. Aspiration pneumonia was seen in 2 patients (4%) in Arm A and in 4 patients (8%) in Arm B, Chi Square value-0.2 (Yate's corrected) P value-0.67. The incidence of febrile neutropenia was 3 and 10 in Arms A and B (6 and 20%) respectively. The tolerance of CCRT in hospitalized patients is marginally better, with relatively few associated complications as compared to outdoor setting. Every institute should promulgate its own guidelines regarding hospitalization of such patients.

Tuberculosis verrucosa cutis presenting with unilateral elephantiasis nostras verrucosa of the left lower limb: A rare entity.

Elephantiasis nostras verrucosa is used to describe lymphedema of the lower limbs caused by a nonfilarial etiology. Infective etiologies include bacterial and fungal infections along with chronic venous stasis, postirradiation, congestive heart failure, obesity, and malignancies, all causes leading to lymphatic obstruction and edema. We herein describe a case of a 70-year-old male who presented with diffuse nonpitting edema of the entire left lower limb with cobblestoning of the surface with a positive Kaposi-Stemmer sign and presence of a verrucous plaque over the left ankle. Histopathology of the verrucous plaque revealed it to be tuberculosis verrucosa cutis (TVC). We report this rare presentation of TVC as a cause of unilateral lymphedema.

To evaluate immunoreactivity of cyclooxygenase-2 in cases of endometrial carcinoma and correlate it with expression of p53 and vascular endothelial growth factor.

CONTEXT: Increased levels of prostaglandins have been detected in cancers of several anatomic sites, including those of endometrium. Several studies have shown that cyclooxygenase-2 (COX-2) expression is aberrantly increased in various human epithelial cancers, and cellular up-regulation of COX-2 may be a common mechanism in epithelial carcinogenesis. AIMS: To examine the expressions of COX-2, p53 and vascular endothelial growth factor (VEGF) in endometrial cancer and their relationships with clinicopathologic characteristics. SETTING AND DESIGN: A retrospective observational study in a tertiary care center of academic and research potential. SUBJECTS AND METHODS: Sections from fifty cases of endometrial carcinoma were stained imunohistochemically with COX-2, p53, and VEGF. The expressions of COX-2, p53, and VEGF in endometrial cancer were examined. RESULTS: COX-2 was positive 19 cases (38%) of endometrial carcinoma. The COX-2 immunopositivity was 50%, 28%, and 41% in Grade 1, Grade 2, and Grade 3; and 27%, 46%, 67%, and 100% cases of Stage I, II, III, IV, respectively. p53 was positive in 24 cases (48%); 0%, 33%, and 67% in Grade 1, Grade 2, and Grade 3; and 27%, 77%, 83%, and 100% cases of Stage I, II, III, IV, respectively. VEGF was positive in 21 cases (42%); of which 0%, 33%, and 67% cases were in Grade 1, Grade 2, and Grade 3; and 17%, 77%, 83%, and 100% cases were in Stage I, II, III, IV, respectively. CONCLUSION: The expression of COX-2 increase with stage of the endometrial tumor and with the expression of p53 and VEGF in the endometrial carcinomas. COX-2 inhibitors may have role in the prevention of endometrial carcinomas in high-risk cases and in preventing recurrences after treatment.

Disease characteristics and treatment attributes of patients admitted to the oncology ward of a tertiary care government hospital.

BACKGROUND: The burden of oncology patients in the most developing countries including India has witnessed a steady, progressive, and significant upward trend attributed mainly to increased life span, availability of better imaging modalities, increased awareness, and lifestyle and environmental changes. The management of such patients in government setup often presents lots of challenges such as advanced stage of presentation, existence of medical comorbid conditions, scarcity of beds, and long multimodal treatment often complicated with therapy-induced toxicities. MATERIALS AND METHODS: A prospective study was undertaken in a Radiation Oncology ward catering to male patients over 6-month duration in a superspecialty hospital of defense services. The clinical, pathological, and treatment-related attributes were recorded. Wherever possible, the clinical course of stay, complications during admission, and the response to primary management were studied. RESULTS: A total of 570 patients were admitted for 6-month duration. Of these patients, 240 were transferred in from other peripheral service hospitals while the remaining were admitted directly from this hospital or transferred from various wards of this hospital. The mean age of the patients was 46.5 years. Most common histology was squamous cell carcinoma. The most common site of primary was head and neck, followed closely by central nervous system tumors and gastrointestinal tract. A total of 185 patients were fresh cases admitted for workup and complete duration of definitive management (of which 82 received concurrent chemoradiation), 280 patients were for follow-up, 70 patients were admitted briefly for supportive care during a while on chemoradiation, and 15 patients were admitted for administrative reasons. Fifty-eight patients developed Grade II and onward therapy-induced hematological, gastrointestinal, cutaneous complications, and 14 patients suffered from febrile neutropenia. Thirty patients developed other significant complications warranting cross-referrals to other specialists. One hundred and thirty patients underwent more than one imaging modalities (contrast-enhanced computed tomography, magnetic resonance imaging, bone scan, and positron emission tomography-computed tomography). The duration of stay varied from 3 to 64 days, with an average duration of 38 days. There were 18 deaths during the study period. CONCLUSION: The course of hospitalization for oncology cases is often prolonged and complicated by significant complications, warranting aggressive supportive care by various concerned specialists. These patients often require multiple imaging for primary and metastatic workup. There is a need for judicious selection of patients meriting admission for optimum utilization of existing resources.

Clinical Profile of Pediatric Oncology Patients Treated by External Beam Radiotherapy: An Institutional Experience.

INTRODUCTION: Pediatric tumors are a heterogeneous group of malignant conditions requiring multimodal treatment, and management of such cases is at time challenging. We present the clinical profile of pediatric cancer patients who received radiation, either alone or as adjuvant to surgery and chemotherapy; in prophylactic, radical or palliative clinical setting. AIM: This study was envisaged to review our experience of pediatric oncology cases, their clinical and morphological profile, dosage schedule of radiotherapy, and the therapy induced complications. SETTINGS AND DESIGN: This was a retrospective, observational study carried out in an apex tertiary care cancer institute of government set-up in a developing country. MATERIALS AND METHODS: The treatment charts and clinical summary of patients who had received radiation over the last 5 years period were retrieved and perused. Various clinical and pathological parameters were studied and inferences drawn. RESULTS: A total of 50 patients got radiation over 5 year study-period, including 37 male and 13 female patients. The commonest age group of presentation was 8-12 years followed by 13-16 years. The mean age of presentation was 9.3 years. The most common diagnosis was hematological malignancies followed by CNS tumors with 21 and 13 patients respectively. Overall the most common indication of RT was in adjuvant setting after surgery as the definitive management, where 24 patients were irradiated; and the next common indication was prophylactic cranial irradiation in 14 patients of childhood leukemias. 10 patients tolerated treatment with Grade 1 site-specific or systemic toxicities while 7 patients developed Grade 2 and more systemic toxicities. 9 patients received craniospinal irradiation, common indications being medulloblastoma and Atypical teratoma rhabdoid tumor (ATRT). 3 patients received concurrent chemotherapy with weekly Inj Vincristine. 17 patients required sedation or short general anaesthesia for radiation planning and execution. CONCLUSION: External beam Radiotherapy constitutes an important component of management of pediatric cancers. One should be judicious in Radiotherapy planning, execution and monitoring acute and delayed toxicities.

CD44 positive/CD24 negative (stem cell like property) breast carcinoma cells as marker of tumor aggression.

BACKGROUND: Cells with stem cell like properties in solid organ malignancies like breast and pancreas have been studied over the last decade and have been found to be associated with poor prognosis. Presence of CD44 positive and CD24 negative tumor cells in breast carcinoma (cells with 'stem cell' like property) as marker of aggressiveness and poor prognosis was checked for association with various markers of disease aggression like age at presentation, size of tumor, histological grade of tumor, triple negative status, level of micro-vessel density, and nodal status. METHODS: Single and double staining immunohistochemistry protocol was used for CD24 and CD44 staining. The staining protocol was repeated with more contemporary techniques using fluorescent chromogen also. RESULTS: 52 cases, all females who underwent modified radical mastectomy at a tertiary care hospital over a period of 3 years, were evaluated. No association was found between presence of stem cells and size of lesion, histological grade, triple negative status or micro-vessel density. However, significant association was found with respect to younger age of presentation (p value = 0.044). 20 out of 25 cases with nodal metastasis were positive for presence of stem cells (p value is 0.0003). Further, 18 of these 20 cases also had stem cells in the metastatic nodule. Fluorescent chromogens (FITC and Cyanine Red) revealed similar results. CONCLUSION: Cases positive for stem cells showed earlier onset of disease and proneness to nodal metastasis.

Profile of patients undergoing palliative radiotherapy: A single-institute study from a tertiary care oncology center.

BACKGROUND: Palliative radiotherapy (PRT) plays a significant role in the palliation of symptoms in patients with cancer and constitutes nearly 50% of the workload in different settings. AIMS: The aim is to study patient-, disease-, and treatment-related characteristics in locoregionally advanced and metastatic malignancies meriting palliative management. SETTING AND DESIGN: This was a retrospective observational study in a tertiary care government institute with academic and research potential. METHODOLOGY: The electronic medical records, medical documents, and radiotherapy (RT) treatment charts were retrieved and studied. OBSERVATIONS: A total of 460 patients were included in the study over 2 years, forming 30% of the total number of patients treated during the study period. Three hundred and ninety-six patients received PRT to the metastatic sites, while 64 patients received extremely hypofractionated PRT to the primary for symptomatic relief. Totally 442 patients showed good symptomatic response to PRT. One hundred and thirty-eight patients underwent re-irradiation. Lung was the most common primary site seen in 155 cases. The most common indication for PRT was palliation of pain from painful metastases as seen in 240 cases, and the next common indication was palliative whole-brain RT for brain metastases as seen in 159 cases. CONCLUSION: PRT forms an integral and important aspect of palliative care to the vast number of patients harboring metastatic disease that warrants some form of treatment for symptomatic relief. Short course of PRT in outdoor setting is a preferred mode of treatment to improve the quality of life of these distressed patients.

Expect the unexpected: Endometriosis mimicking a rectal carcinoma in a post-menopausal lady.

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

Cutaneous metastasis as primary presentation in unsuspected carcinoma esophagus: Report of two cases.

Cutaneous metastasis from carcinoma esophagus is an extremely rare occurrence. It accounts for less than 1% among all cases of metastatic carcinoma esophagus. We present two such unusual cases in which the primary manifestation was cutaneous lesions. Histology from the biopsy of the lesion in one case was reported as adenocarcinoma and while that from the other case was reported as squamous cell carcinoma. A search for primary revealed previously unsuspected carcinoma esophagus in both the cases. The patients subsequently developed metachronous systemic lesions and expired within 5 months of appearance of the index skin lesion.

Fertility preservation in young patients with cancer.

Infertility can arise as a consequence of treatment of oncological conditions. The parallel and continued improvement in both the management of oncology and fertility cases in recent times has brought to the forefront the potential for fertility preservation in patients being treated for cancer. Many survivors will maintain their reproductive potential after the successful completion of treatment for cancer. However total body irradiation, radiation to the gonads, and certain high dose chemotherapy regimens can place women at risk for acute ovarian failure or premature menopause and men at risk for temporary or permanent azoospermia. Providing information about risk of infertility and possible interventions to maintain reproductive potential are critical for the adolescent and young adult population at the time of diagnosis. There are established means of preserving fertility before cancer treatment; specifically, sperm cryopreservation for men and in vitro fertilization and embryo cryopreservation for women. Several innovative techniques are being actively investigated, including oocyte and ovarian follicle cryopreservation, ovarian tissue transplantation, and in vitro follicle maturation, which may expand the number of fertility preservation choices for young cancer patients. Fertility preservation may also require some modification of cancer therapy; thus, patients' wishes regarding future fertility and available fertility preservation alternatives should be discussed before initiation of therapy.

Ectopic thymoma presenting as a large intrathoracic mass.

Thymoma is an epithelial neoplasm of the thymus, which commonly lies in the anterior mediastinum. Unusually it can be found in other locations as well. Ectopic thymoma rarely presents as an intrathoracic tumor. We report a case of an ectopic thymoma presenting as a giant right intrathoracic tumor that was treated with resection. The patient was a 49-year-old postmenopausal lady who presented with heaviness in chest and breathlessness. Detailed investigation including chest computed tomography scan and magnetic resonance imaging revealed a well-defined large solid tumor in the right thoracic cavity. Surgery was performed based on the radiological findings. A large solid tumor measuring 12 cm x 10 cm x 8 cm was found in the thoracic cavity, adherent to the pericardium, diaphragm and the right mediastinal pleura without apparent invasion. The tumor was completely resected. The diagnosis given as World Health Organization classification-Type B1 Muller-Hermelink classification-predominantly cortical thymoma.

Comparison of sequential chemoradiation with radiation alone in the treatment of advanced head and neck cancers.

OBJECTIVES: To compare locoregional control with alternating chemo radiation and radiation alone in patients with locally advanced head and neck carcinoma. STUDY DESIGN: A prospective randomized study. SETTING: Tertiary academic referral center. PATIENTS: 50 patients of biopsy proven locally-advanced carcinoma of head and neck. INTERVENTION: 25 patients were kept in Group I or study group (i.e. alternating chemo-radiation) and 25 patients in Group II or control group (i.e. radiation alone). In the study group, patients were given 3 cycles of chemotherapy (Cisplatin 20 mg/m([2]) and Inj. 5-FU 200mg/m([2]) from day 1-5 of each week) during weeks 1,5 and 9 alternated with radiation dose of 10Gy/week was given during weeks 2,3,4 and 6,7,8. In the control group, patients were given a total dose of 60Gy in 6 weeks. OUTCOME MEASURES: The response rate at the primary site and nodal site was better in study group as compared to control group. RESULTS: On comparing the response at the primary and nodal site together, 72% (18/25) patients of group I and 44% (11/25) patients of group II showed CR. PR was seen in 28% (7/25) and 36% (9/25) patients in group I and II respectively. No response was seen in 5/25 (20%) of patients in Group II. CONCLUSION: Our study has revealed that alternating/ sequential chemoradiation is a promising and feasible approach for patients in advanced head and neck cancer.