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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 4 | Issue 2
Page Nos. 61-143

Online since Wednesday, February 23, 2022

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ORIGINAL ARTICLES  

Weekly vs. daily low dose cisplatin in chemoradiation of locally advanced head and neck cancers: Comparison of compliance and clinical outcomes p. 61
Ayush Garg, Piyush Kumar, Pavan Kumar, Arvind K Chauhan
DOI:10.4103/jco.jco_23_21  
Aim: Concurrent cisplatin with radiotherapy improves outcomes in locally advanced squamous cell carcinomas of the head and neck cancers. Cisplatin has been used in different doses in various schedules. The present study is designed to evaluate the compliance, clinical outcomes, and long-term side effects in two different dose schedules of cisplatin used as concurrent therapy with radiotherapy. Materials and Methods: A total of 50 patients were included in the study from November 2015 to March 2017 with 25 patients in each group. The total radiotherapy dose planned was 70 Gy/35 fractions in 7 weeks, along with either cisplatin 35 mg/m2 weekly (Group I) or 6 mg/m2 daily (Group II). Assessment of toxicity was done by the RTOG scoring criteria. The WHO Response criterion was used to assess clinical response. Results: The compliance for radiotherapy treatment (80% vs. 84%) and chemotherapy cycles (52% vs. 60%) was almost similar in both the groups with no statistical difference seen. At the end of 3 months, Group II (60%) had better complete response than Group I (40%), although the difference was not statistically significant (P = 0.08). During treatment, no Grade III/IV hemoglobin toxicity was observed in either of the groups. Grade III/IV mucositis was predominant in Group II with 40% vs. 24%; P-value was not statistically significant. No Grade III/IV xerostomia was seen in either of the groups. The median follow-up of patients is 15 months. The median overall survival (11 vs. 6 months) and disease-free survival (4 vs. 2 months) are less in patients who received daily cisplatin infusion as concurrent therapy, although the difference is not statistically significant. Conclusion: Low dose cisplatin with radiotherapy appears feasible and is a logistically suitable “outpatient” option without increasing long-term toxicity.
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Step-by-step stereotactic radiotherapy planning of vestibular schwannoma: A guide to radiation oncologists—the ROSE case (Radiation Oncology from Simulation to Execution) p. 68
Kanhu Charan Patro, Ajitesh Avinash, Arya Pradhan, Pamidimukkala Venkatramana, Chittaranjan Kundu, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Mrutyunjayarao Muvvala Rao, Arunachalam Chithambara Prabu, Ayyalasomayajula Anil Kumar, Srinu Aketi, Parasa Prasad, Venkata Naga Priyasha Damodara, Veera Surya Premchand Kumar Avidi, Mohanapriya Atchaiyalingam, Keerthiga Karthikeyan, Voonna Muralikrishna
DOI:10.4103/jco.jco_35_21  
Background: Vestibular schwannoma (VS) is a slow-growing tumor that represents 90% of all tumors at the cerebellopontine angle. One of the main modalities of the treatment is stereotactic radiotherapy (SRT). Here, we describe procedure details for stereotactic planning of VS. Methods: The step-by-step procedure for stereotactic planning of pituitary adenoma has been described using a clinical scenario of VS. Results: The stereotactic radiation planning of VS starts with the basic history and relevant evaluation of symptoms such as tinnitus, dizziness, and facial symptoms. Magnetic resonance imaging (MRI) of the brain is the imaging modality of choice. The radiation planning of VS starts with computed tomography (CT) simulation and MRI of the brain that should be performed in prescribed format to achieve uniformity in radiation planning. After CT and MRI fusion, contouring of target, organs at risk (OAR), and radiation planning should be performed. The plan evaluation includes target and OAR coverage index, conformity, homogeneity and gradient index, and beam arrangement. After radiation plan evaluation, treatment is delivered after quality assurance and dry run. Conclusion: The article highlights the sequential process of radiation planning for SRT of VS—starting from simulation to planning, evaluation of plan, and treatment.
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Prevalence of vitamin D deficiency in patients with cancer and the need for routine screening and supplementation of vitamin D in patients with cancer p. 76
Ravishankar Bellala, Venkata Madhavi Bellala, Dikkala Srikanth, Sivaramakrishna Talluri, Prithvi Raj Bellala, Rishik Bellala
DOI:10.4103/jco.jco_31_21  
Context: The prevalence of Vitamin D deficiency in the general population in India ranges between 60% and 80% depending on dietary habits, occupation, and cultural practices. Deficiency of Vitamin D has been associated with an increased risk of colon cancer, breast cancer, prostate cancer, and ovarian cancer. The anticancer effects of Vitamin D have been attributed to its antiproliferative, anti-inflammatory, and antiangiogenic actions. This study aims at observing the magnitude of Vitamin D deficiency in patients with cancer and at stressing the importance of routine screening and supplementation of Vitamin D. Aim: To study the prevalence of Vitamin D deficiency in patients with cancer. Settings and Design: An analysis to study Vitamin D deficiency in patients with cancer. Materials and Methods: A consecutive observational study was conducted at Queen’s NRI hospital, Omega hospital Visakhapatnam, from April 2018 to September 2020. Blood samples of 157 patients attending follow-up clinics and patients receiving active treatment were collected. Serum total Vitamin D was estimated using the electrochemiluminescence (ECL) method on Cobas E411 autoanalyzer. They were categorized into (1) deficient (vitamin D ≤20 ng/ mL), (2) insufficient (vitamin D between 20 and 29 ng/ mL), (3) sufficient (vitamin D ≥30–100 ng/mL), and (4) toxicity (vitamin D ≥30–100 ng/mL) and analyzed statistically. Statistical Analysis Used: Computer-based calculations were used for analysis of the collected data. Results: Among the 157 patients included in the study, 21 (13.3%) were having sufficient level, 21 (13.3%) insufficient, and 115 (73.2%) deficiency of vitamin D. The patients included in this study comprised 44 patients with breast cancer, 40 patients with cervical cancer, 47 patients with head and neck cancer, 10 patients with colon cancer, and 16 patients with cancers of other sites. Conclusion: In our evaluation, we found that more than 70% of patients with cancer attending our hospital are having vitamin D deficiency according to our study.
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Aberrant thyroid transcription factor-1 expression in ovarian and nasopharyngeal carcinoma: Case reports with review of literature p. 86
Meenakshi Kamboj, Sunil Pasricha, Anurag Mehta, Gurudutt Gupta, Anila Sharma, Garima Durga, Divya Bansal
DOI:10.4103/jco.jco_30_21  
Introduction: Thyroid transcription factor-1 (TTF-1) is the recommended and sensitive immunohistochemical (IHC) marker for diagnosing lung adenocarcinomas and thyroid neoplasms, at the primary as well as the metastatic site, and is useful to rule out these sites in cases with adenocarcinomas of unknown primary. However, aberrant nuclear TTF-1 expression has also been reported in malignancies arising from gastrointestinal tract (GIT), breast carcinoma, female genital tract (FGT), and colon. Here, we present our experience of aberrant expression of TTF-1 in ovarian and nasopharyngeal carcinoma (NPC). Materials and Methods: TTF-1 immunostain was performed on 16 cases of NPC using clones SP141 and 8G7G3/1. A case of ovarian serous carcinoma with aberrant TTF-1 expression has also been discussed. Results: Of 16 cases of NPC, 2 cases (12.5%) showed strong TTF-1 expression with clone SP141, while all were negative with 8G7G3/1. In one of the case initial diagnosis of metastatic lung adenocarcinoma was made on cervical node biopsy as the tumor was negative for p40 and showed strong nuclear positivity for TTF-1 (SP141 clone). However, on clinical suspicion of NPC Epstein-Barr virus-encoded small RNA (EBER) by in situ hybridization was performed which was positive, and repeat TTF-1 using clone 8G7G3/1 was negative, suggested a NPC. In the case of ovarian tumor, cells were strongly positive for CK7 and TTF-1 (SP141 clone) expression, and thus the tumor was erroneously diagnosed as metastatic adenocarcinoma from a primary lung. However, IHC in the resected specimen showed strong expression for PAX-8 and TTF-1 using SP141 clone, while negative with clone 8G7G3/1 clone (Ventana), leading to final diagnosis of high-grade serous carcinoma of ovary with aberrant TTF-1 expression. In this case, addition of PAX-8 in initial biopsy diagnosis would have saved from labeling it as primary from lung. Conclusion: The sensitivity and aberrant expression vary between the various antibody clones used, with increased expression seen by SP141 clone as compared to 8G7G3/1 in our cases. Our findings highlight the significance of using a panel of diagnostic IHC markers before final diagnosis and importance of clinical details.
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Step by step stereotactic planning of meningioma: A guide to radiation oncologists—the ROSE case [radiation oncology from simulation to execution] p. 92
Kanhu Charan Patro, Ajitesh Avinash, Arya Pradhan, Suresh Tatineni, Chittaranjan Kundu, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Mrutyunjayarao Muvvala Rao, Arunachalam Chithambara Prabu, Ayyalasomayajula Anil Kumar, Srinu Aketi, Parasa Prasad, Venkata Naga Priyasha Damodara, Veera Surya Premchand Kumar Avidi, Mohanapriya Atchaiyalingam, Keerthiga Karthikeyan, Voonna Muralikrishna
DOI:10.4103/jco.jco_36_21  
Background: Intracranial meningiomas account for 33% of all primary tumors of the brain. One of the main modalities of the treatment is stereotactic radiosurgery (SRS). Here, we describe the procedural steps for radiation planning of stereotactic radiotherapy (SRT) of meningioma. Methods: The step-by-step procedure for stereotactic planning of meningioma has been described using a clinical scenario of meningioma. Results: The stereotactic radiation planning of meningioma starts with the basic history and relevant clinical evaluation of various signs and symptoms of the patient followed by imaging and grading of meningioma. Magnetic resonance imaging (MRI) of the brain is the imaging modality of choice. Evaluation of surgical notes and postoperative histopathology confirmation of diagnosis should also be done. Radiation is indicated in postoperative residual or recurrent disease and in unresectable settings. The radiation planning of meningioma starts with computed tomography (CT) simulation and MRI of the brain that should be performed in prescribed format to achieve uniformity in radiation planning. After CT and MRI fusion, contouring of target, organs at risk (OAR), and radiation planning should be performed. The plan evaluation includes target and OAR coverage index, conformity, homogeneity and gradient index, and beam arrangement. After radiation plan evaluation, the treatment is delivered after quality assurance and dry run. Conclusion: The article highlights the sequential process of radiation planning for SRT of meningioma—starting from simulation to planning, evaluation of plan, and treatment.
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REVIEW ARTICLES Top

Adjuvant chemotherapy for stage II colon cancer: Whom to treat? p. 102
Deep S Pruthi, Manish B Pandey, Puneet Nagpal
DOI:10.4103/jco.jco_20_21  
The treatment of choice in stage II colon cancer is surgery, which alone has shown a high cure rate (about 80%). The role of adjuvant chemotherapy is still a matter of debate. This clinical issue leads to the need for identifying patients who may benefit from postoperative chemotherapy based on their risk of recurrence. Patients with stage II colon cancer need to be stratified according to risk factors, which can be either clinical or pathological. In this review article, we analyzed various risk factors individually and try to quantify the relative contribution of each factor. We also analyzed various chemotherapy regimens and their duration as well.
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HPV and cervical cancer: An immunological aspect p. 108
Sanjay Singh, Sukanya Tripathy, Mohit Kumar Rai, Durga Prasanna Misra, Vikas Agarwal
DOI:10.4103/jco.jco_18_21  
Evidence supports that the occurrence of cervical cancer is mainly due to viral infection and the most common virus found in association with this type of cancer is the Human papillomavirus (HPV), a DNA virus. The reason for virulence is its integration in the host’s genome and continual activity of E6 and E7 proteins, which further interfere with the tumor suppressor protein’s activity. The International Agency for Research on Cancer has classified 12 HPV types as group 1 carcinogens that have a high risk of carcinogenicity. Due to lack of access and utilization of preventative health care, the occurrence and death rates from cervical cancer remain considerable. The diagnosis of cervical cancer can be done through cytological screening programs and microbial screening. Knowing the microenvironment for the development of such a type of cancer plays a prominent role in the identification of preventive measures. Prevention of this type of cancer can be done through diagnosis at an early phase, with primary prevention using vaccines and secondary prevention using a highly sensitive HPV-DNA test and by propagating the knowledge of such infection and its cure. New biomarkers will be important to decide who among the HPV-positive women needs to be referred for further evaluation or treatment. The implementations of new prevention strategies is very important to completely eradicate such cancers. In this review, the microenvironment, etiology, and epidemiology of cervical cancer have been emphasized.
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Hippo pathway in cancer: Examining its potential p. 115
Mohammad Z Najm, Sadaf , Vyas M Shingatgeri, Harsh Saha, Hiya Bhattacharya, Archita Rath, Vibhuti Verma, Apurva Gupta, Abdulaziz A Aloliqi, Poonam Kashyap, Farah Parveen
DOI:10.4103/jco.jco_9_21  
The Hippo pathway was first discovered and linked to human cancers in the year 2002. It plays a crucial role in the majority of cancers, making it a censorious field for future investigation. Cancer is one of the major health issues, and there is no current cure accessible to efficiently medicate or treat the disease. The disease follows a process of oncogenesis, leading to the transformation of healthy cells (controlled and regulated growth) into cancer cells (uncontrolled and dysregulated growth). Previous studies reveal that the role of the Hippo pathway remains the center in the modulation of developmental biology. The mutated and altered gene expression of LATS1/2 (Large Tumor Suppressor kinase), MST1/2 (Member of Sterile-20 proteins kinase), and YAPs (Yes Associated Proteins), which are the chief factors of the Hippo pathway, basically promotes the invasion and migration of cancer cells. Therefore, targeting the hippo pathway genes is of utmost importance when considering new treatment strategies such as precision or personalized medicine. In this review, we aim at describing how microRNAs, hippo-signaling pathways regulate and maintain the whole hippo signaling.
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Emergence of SBRT in borderline resectable pancreatic cancer: Is it the way forward? p. 121
Kaustav Talapatra, Shreyasee Karmakar, Ajinkya Gupte, Amrita Srivastava
DOI:10.4103/jco.jco_22_21  
Pancreatic cancers are aggressive cancers with poor survival outcomes and few effective treatment modalities. The previously used protracted chemo-radiotherapy (CTRT) regimens have not had encouraging results. Stereotactic body radiotherapy (SBRT) has shown encouraging results in the treatment paradigm of borderline resectable pancreatic cancers. Though body of level I evidence is weak currently, studies have shown better resectability with negative margins with neoadjuvant SBRT. Precise contouring, good image guidance, strict quality assurance, and multi-disciplinary spatial co-operation are crucial for its success. High biologically effective dose, smaller margins, short duration of treatment, and strategic sequencing are the key to better outcomes.
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RESIDENTíS CORNER Top

Tumors beneath one umbrella: A story of a young man p. 127
Anurag Mehta, Diksha Karki, Garima Durga, Divya Bansal, Vishal Yadav, Sunil Pasricha, Meenakshi Kamboj
DOI:10.4103/jco.jco_43_21  
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Primary Ewing’s sarcoma of vagina in young female: A rare entity p. 133
Jitin Goyal, Jeevitesh Khoda, Ruchir Jyani, Ankur Kumar, Sunil Kumar Puri, Anila Sharma, Arvind K Chaturvedi
DOI:10.4103/jco.jco_42_21  
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CASE REPORTS Top

Cancer of right breast with single-liver metastasis-simultaneous treatment of chest wall with radiotherapy for carcinoma breast and SBRT for liver lesion: Procedural details of the complex procedure p. 136
Kanhu Charan Patro, Venkata Naga Priyasha Damodara, Rakesh Reddy Boyya, Chitaranjan Kundu, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Sanjukta Padhi, Mrutyunjayarao Muvvala, P Srinivasuslu Reddy, Veera Surya Premchand Kumar Avidi, Mohanapriya Atchaiyalingam, Keerthiga Karthikeyan, Arunachalam Chithambara Prabu, Aketi Srinu, Parasa Prasad, Ayyalasomayajula Anil Kumar
DOI:10.4103/jco.jco_33_21  
Breast cancer with oligometastasis is not uncommon. Greater therapeutic advantage has been reported in various literatures with evolution of treatment technique. Here we report a case of ductal carcinoma right breast with a single metastasis to liver. This patient was treated with radical intent with chemotherapy, surgery, and then followed by radiotherapy to right chest wall along with stereotactic body radiotherapy for liver metastasis. Each treatment per se is not complicated. When radiation delivered to both chest wall and liver, the cumulative dose to liver is the main concern. Here we present the procedural details of this complex procedure.
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Squamous cell carcinoma of tongue with isolated inguinal node metastasis: A case report and literature review p. 140
Keerthiga K , Chitta Ranjan Kundu, Kanhu Charan Patro, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Sanjukta Padhi, M Mrityunjaya Rao, P Srinivasuslu Reddy, A Mohanapriya, V S Premchand Kumar Avidi, Venkata Naga Priyasha Damodara
DOI:10.4103/jco.jco_29_21  
Most of the patients with squamous cell carcinoma of tongue present with distant metastasis to lung, bone, and liver. However, some rare presentation of tongue cancer metastasizing to cutaneous, cardiac, and axillary lymph nodes has been reported. We present a case of 55-year-old man diagnosed with squamous cell carcinoma of right lateral border of tongue, underwent right hemiglossectomy and right modified neck dissection, levels 1–5 with pathological staging pT2N0M0 (AJCC 8th edition) followed by adjuvant radiotherapy to a total dose of 60 Gy in 30 fractions. After 6-month post-treatment, the patient presented with right inguinal swelling which was associated with pain. Ultrasonography of the groin region confirmed lymphadenopathy and fine-needle aspiration cytology (FNAC) from lymph node came out as metastatic deposits of squamous cell carcinoma. Positron emission tomography and computed tomography (PET-CT) showed isolated right inguinal lymph node metastasis. He underwent right inguinal block dissection and adjuvant radiotherapy. Hence, isolated inguinal node metastasis is extremely rare but possible. Patient should be examined thoroughly during follow-up.
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