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Globally and in India, lung cancer is one of the leading malignancies in terms of incidence and mortality. Smoking and environmental pollution are the common risk factors for developing lung cancer. Traditionally, lung cancer is divided into small cell and nonsmall cell types, with nonsmall cell carcinomas including squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.In this review article, we describe the imaging recommendations and findings in the diagnosis, staging, and management of lung cancer, including the imaging of treatment-related complications.

Aim: This study aimed to identify DPYD variants and the related but previously unexplored phenotype (plasma uracil, dihydrouracil [DHU], and the DHU-to-uracil ratio) in a healthy adult Indian population. Methods: Healthy adult volunteers (n = 100) had their uracil and DHU levels measured and were genotyped for selected variants. Results: Among the nine variants studied, c.1906-14763G>A and c.85T>C were the most prevalent. Participants with any of the variants except for c.85T>C and c.1627A>G had a significantly lower DHU-to-uracil ratio and those with c.1905+1G>A variant had significantly increased uracil concentration compared with wild-type. Conclusion: Participants with five variants were identified as having altered phenotypic measures, and 40% of the intermediate metabolizers had their phenotype in the terminal population percentiles.

Dose-dense chemotherapy improves survival but with increased toxicity and treatment-related cost. We report the prevalence of anemia and the possible risk factors associated with chemotherapy-related anemia and determine the cost and time-delay associated with transfusion requirement in Indian patients with non-metastatic breast cancer on dose-dense preoperative chemotherapy.In this study, triple-negative breast cancer (TNBC) patients were treated preoperatively with docetaxel and cyclophosphamide alternating with epirubicin and cisplatin every 2 weeks. Patients were evaluated for anemia pre- and post-chemotherapy. We examined trends in the red cell indices, transfusion requirement, time to transfusion, as well as risk factors associated with transfusion during treatment, along with delay in treatment due to anemia and the additional cost incurred.A total of 116 consecutive women with nonmetastatic TNBC were treated with preoperative chemotherapy. The median age was 44.5 years. 56.1% of patients had stage III disease. Anemia was detected at baseline in 54 (46.5%) patients with mild anemia (10-12 g/dl) in 42 (36.2%) patients and moderate anemia (8-10 g/dl) in 12 (10.3%) patients. During the course of treatment, all patients developed anemia. A total of 44 patients (37.9%) required transfusion during chemotherapy, with 55(47.4%) patients developing grade 1-2 anemia and 40 (34.5%) patients developing grade 3 anemia. The factors associated with anemia requiring transfusion were a steeper decline in hemoglobin after two cycles (OR 1.65, p = 0.02), low-grade tumor (OR 2.48, p = 0.03), and thrombocytopenia grade 3 or 4 (OR 4.35, p = 0.034), of which tumor grade and thrombocytopenia remained significant in multivariate analysis. Nearly one-fourth of the study population had a delay between two cycles of chemotherapy due to anemia. A median additional cost of INR 7000 was incurred among those requiring blood transfusion.Anemia is a common toxicity associated with dose-dense chemotherapy during curative breast cancer treatment leading to delay in treatment and increased cost. Low-grade tumor, grade 3 or 4 thrombocytopenia, and grade 2 or higher anemia after two cycles of chemotherapy are risk factors for blood transfusions during treatment.

Purpose The addition of carboplatin has improved pathological complete response (PCR) and event-free survival (EFS) and is becoming a new standard of care for early triple-negative breast cancer (TNBC). However, this comes at the expense of increased toxicity. Here, we aimed to evaluate a novel cisplatin-based chemotherapy regimen for early TNBC. Methods Women with early TNBC who were administered neoadjuvant chemotherapy consisting of four cycles of docetaxel and cyclophosphamide alternated with cisplatin and epirubicin (ddDCEP) given every two weeks over a 16-week period were analyzed in this retrospective real-world study, driven by physician preference. The major outcomes assessed were PCR and EFS. Other outcomes included overall survival, treatment delivery, and adverse events. Results From January 2017 to January 2020, 116 women with stage I-III TNBC received neoadjuvant ddDCEP. PCR (ypT0/TisN0) was observed in 55.2% of evaluable patients. The PCR in stage I/II disease was 62.2%, and stage III was 49.5%. 37.9% of patients developed grade 3 anemia during treatment. Incidence of grade 3/4 neutropenia was 16.3%, and febrile neutropenia was 4.3%. 86% of patients completed all 8 cycles of planned chemotherapy, and 98% at least 6 out of 8 cycles. 12% patients required dose reduction of taxane and 19% for cisplatin. At 30 months of median follow-up, the EFS was 91.2%, and overall survival was 97%. Cost analysis showed this regimen was more cost-effective than carboplatin-based regimens. Conclusion Treatment with ddDCEP led to pCR in a significant proportion of patients, with high completion rates and lower toxicity, particularly neutropenia. These findings suggest that ddDCEP may be a promising, cost-effective treatment option for early TNBC.

PURPOSE Preoperative long course chemoradiation (LCCRT) followed by total mesolectal excision (TME) results in excellent local control but distant failure rates remain high. Total neoadjuvant therapy (TNT) with pre-operative delivery of systemic chemotherapy and chemoradiotherapy results in a higher pathological response, improved event free and overall survival and is becoming the new standard of care. We describe our experience with a hybrid TNT consisting of induction chemotherapy followed by chemoradiotherapy using full dose 5FU without oxaliplatin. METHODS In this single center study, adults with a LARC were included. Patients were eligible if they were aged 18 years or older, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0–1, biopsy-proven, newly diagnosed LARC, which was classified as high risk on pelvic MRI (with at least one of the following criteria: clinical tumor [cT] stage cT4a or cT4b, extramural vascular invasion (EMVI), clinical nodal [cN] stage cN2, mesorectal fascia involvement and enlargement/tumor deposits on lateral lymph nodes). The hybrid TNT protocol comprised of six biweekly courses of modified FOLFOX6 (m FOLFOX6) followed by addition of pelvic LCCRT with four concurrent cycles of biweekly 5-FU 2600 mg/m2 + LV 200 mg/m2 without oxaliplatin to complete uninterrupted 20 weeks of full dose 5FU + LV chemotherapy. Pelvic chemoradiotherapy consisted of 28 daily fractions of 2 Gy up to 50.4-54Gy including boost to extra-mesorectal nodes. Surgery was planned 11-13 weeks after completing chemoradiotherapy. Outcomes of interest were pathological complete response (pCR), 2 year disease free survival (DFS) and overall survival (OS). RESULTS Between July 2017 to August 2020, 84 adults, predominantly male (65.5%) aged 42.5±13 years with LARC were treated with the TNT protocol. High risk features were T3/T4 in 80 (95.3%), N2 nodes 51(60.7%), signet ring cell histology 22(26.2%), meso-rectal fascia involvement 73(86.9%), EMVI 54 (64.3%) and lateral pelvic nodes 25(29.8%). Eighty- one (96.4%) completed all planned chemotherapy. All but two patients completed the planned RT. pCR was noted in 27 (32%). Twenty-five (29%) did not undergo surgery- 6(7%) opted for non-operative management (NOM) after complete clinical response (cCR), 5 refused surgery, 13(15.4%) were deemed inoperable due to inadequate tumor regression despite TNT (R0 resection was not feasible) and 2 did not complete treatment. Grade 3 &4 toxicities included neutropenia in 20 (23.8%), diarrhea in 12 (14.2%) and anemia in 9(10.7%) patients. Grade 5 toxicities were seen in one patient who died from neutropenic sepsis, and another who developed a cerebrovascular accident on therapy. After 24.5 months of median follow-up, 23 (27%) patients recurred, with local recurrence in 5(6%), systemic recurrence in 16 (19%) and both in 2(2.4%). The median disease-free survival (DFS) of the whole cohort was 22.5 months. Those who did not undergo surgery(n=19) despite residual disease (no cCR) had the worst outcomes (mDFS 11.4 months versus 27.7months, p= and mOS 15 months versus 29.2 months p= CONCLUSION The hybrid TNT regimen was administered without significant dose delays or interruptions. Toxicity was manageable but with two treatment related deaths. pCR of 32% is comparable to contemporary trials, however the 2-year recurrence rates were not improved. Ability to undergo surgery after TNT predicted for improved DFS and OS.

Background Triple-negative breast cancer (TNBC) with residual disease post chemotherapy, have increased chance of relapse and lower survival with varying degree of pathological complete response (pCR) after neoadjuvant chemotherapy (NAC). However, the risk of recurrence is high among those who do not achieve pCR and characterizing the mutational landscape of this fairly heterogeneous subset of patients might provide some valuable insights. Methods The archival paired (pre- and post-NAC) samples of 25 patients with histopathologically confirmed TNBC with residual disease who received anthracycline-taxane as NAC, were processed by next-generation sequencing using a 72-gene panel. Somatic mutations were identified using UMI corrected .clc pipeline; gene annotation of the variants performed using VeP program. Data was analysed using IBM SPSS Statistics v23 and R v4.1.2 (RStudio 2021.09.1). The K-means algorithm was used to classify the samples into k number of clusters. Results Among all 50 tumour samples, a median of 12 mutations (IQR 7-17.25) per sample was observed. Missense mutations accounted for the overwhelming majority (73.5%). The predominant mutations in the pre-NAC samples were TP53(80%), PMS2(64%), PTEN(64%), ERBB2(48%), NOTCH1(44%) while the mutational profile was slightly different among the post-NAC samples: TP53(84%), AR(60%), PTEN(60%), PMS2(44%), ERBB2(40%). The burden of mutations did not differ among patients who received platinum or not (12.8 ± 6.9 Vs 11.25 ± 4.9; p-value 0.94), though there were several private mutations in the former group. Similarly, the tumor mutation burden was not very different among those with (n = 5) and without recurrence (14 ± 7.2 Vs 12.2 ± 6.6; p-value 0.49). The K-means clustering demonstrated two clusters -all patients with recurrence, except one, in the larger cluster. Conclusions The burden of mutations among the pre- and post-NAC samples mostly remained the same, although, mutations in specific genes for example- increase in mutations in the AR gene post-NAC, was noted. TP53 mutations predominated pre- and post-NAC. There was no significant difference in mutational burden and there were no recurrent / co-occurring mutations among those who received platinum therapy after NAC or among those with recurrence. The data throws significant light on the somatic mutational load, spectrum and heterogeneity, among TNBCs with residual disease.

Purpose In a developing country like India, genomic data sets for even the most clinically relevant genes like BRCA1 and BRCA2 is rather scarce. Also, there is a need to identify and screen population specific BRCA hotspots to pave a way for affordable genetic testing strategies in clinical practice. Method This is an ambispective study to evaluate an NGS based approach to identify pathogenic variants in BRCA1 and BRCA2 genes among 430 patients with Breast and Ovarian cancers. The target enrichment was carried out using the in-house designed Multiplex-PCR followed by targeted Next-generation sequencing (NGS) for BRCA1 and BRCA2. Also, allele-specific PCR based genotyping of del185AG was carried out in additional 120 patients. Results In this study, we have identified 100 BRCA1 and BRCA2 variants and based on ACMG 2015 guidelines, these variants were classified as 46 pathogenic, 9 likely pathogenic, and 45 VUS. Of these variants, three were novel, two with likely pathogenic, and one variant of uncertain significance (VUS). The 185delAG was identified as a recurrent mutation in the Southern Indian population accounting for 25.45% of the pathogenic variants. In addition, a family history of cancers of the breast, ovary, pancreas, or prostate (BOPP) was found to be associated with a higher risk of identifying a deleterious BRCA1/2 variant [OR 3.2 (95%CI 1.84–5.77) p ≤ 0.001]. Conclusions These results suggest that Multiplex PCR-NGS is a sensitive and specific strategy for BRCA testing. However, ASPCR-based genotyping of BRCA1(NM_007300.4): c.68_69del followed by targeted NGS would be a cost-effective approach in south Indian patients.

Purpose Carboplatin-containing treatment regimens in early TNBC have shown improved pCR(pathological complete response) and better EFS(event-free survival) but at the expense of increased toxicity, often leading to compromised delivery of planned treatment. We aimed to evaluate a novel alternating regimen to incorporate platinum in early TNBC. Methods We analyzed the data of women with early TNBC who were treated with four cycles each of docetaxel(D;75 mg/m2) and cyclophosphamide(C;600 mg/m2) alternating with cisplatin(P;60 mg/m2) and epirubicin(E;90 mg/m2) (ddDCEP) given every two weeks over a duration of 16 weeks. Pathological complete response was the primary endpoint assessed, along with treatment delivery, adverse events, and survival. Results A total of 116 women with stage I-III TNBC received neoadjuvant ddDCEP. Pathological complete response(pCR) defined as no residual invasive cancer in both breast(T0/Tis) and axilla(N0), was observed in 55.2% of all evaluable patients. The proportion of pCR in stage I/II disease was 62.2%, and stage III was 49.5%. 37.9% of patients developed grade 3 anaemia. Grade 3/4 neutropenia occurred in 16.3%, and febrile neutropenia in 4.3% of patients. 86% of patients completed all 8 cycles of chemotherapy, and 98% at least 6 out of 8 cycles. 12% of patients required a dose reduction of taxane, 13% for epirubicin, and 19% for platinum. The proportion of patients requiring dose reduction and the average total dose reduction was significantly higher in the pCR compared to the no pCR group for cisplatin and epirubicin. At 2 years of median follow-up, the recurrence-free survival was 91.2%, and overall survival was 97%. Conclusion In non-metastatic TNBC, treatment with ddDCEP as neoadjuvant therapy resulted in a high pCR(55.2%) proportion allowing good delivery of all planned therapy with manageable toxicity.

Since majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.

The literature on management of recurrent/metastatic uterine leiomyosarcomas is limited and metastasis to the abdominal wall is very rare. We operated on a 46-year-old woman who had a total abdominal hysterectomy elsewhere for a uterine tumor and presented with recurrence to the anterior abdominal wall, 9 months after the primary surgery. There were two large ulcerated abdominal wall masses. The challenge after complete excision of the tumor was to reconstruct the abdominal wall. We were able to close the defect with a dual mesh and a fasciocutaneous flap from the anterolateral thigh. She received adjuvant chemotherapy with gemcitabine and docetaxel. At the completion of chemotherapy, she was well and apparently disease free. She recurred in the left inguinal node after 9 months but responded to oral pazopanib followed by chemotherapy. This case report highlights the rare possibility of abdominal wall metastasis after initial surgery for leiomyosarcoma. It shows that good quality of life can be achieved by a multidisciplinary treatment of abdominal wall metastasis of uterine leiomyosarcoma.

Purpose: Dose dense chemotherapy improves survival but also increases toxicity and treatment related cost. Here we report the prevalence of anemia, understand the risk factors of chemotherapy related anemia and determine the cost and time-delay associated with transfusion requirement in Indian non-metastatic breast cancer patients on dose dense preoperative chemotherapy.Methods: In this study, 116 triple negative breast cancer (TNBC) patients were treated preoperatively with Docetaxel and Cyclophosphamide alternating with Epirubicin and Cisplatin every 2-weekly. Patients were evaluated for anemia pre- and post-chemotherapy. We examined trends in the cell counts, transfusion requirement, time to transfusion as well as risk factors associated with transfusion during treatment, along with delay in treatment due to anemia and the additional cost incurred.Results: One hundred and sixteen women with high-risk non-metastatic TNBC were treated. Median age was 44.5 years. 56.1% had stage III disease. Delivery of 6/8 planned doses was achieved in 98.3% of patients, and all 8 doses in 86% patients. Anemia was detected at baseline in 54(46.5%) patients with mild(10-12g/dl) anemia in 42(36.2%) patients and moderate(8-10g/dl) in 12(10.3%) patients. Forty-four patients (37.9%) required transfusion during chemotherapy with 55(47.4%) patients having grade 1-2 anemia and 40(34.5%) patients having grade 3 anemia. The factors associated with transfusion were low grade of tumor (OR 2.48 (95% CI 1.08 - 5.68), p = 0.025), hemoglobin post 2 cycles of chemotherapy (OR 1.74 (95% CI 1.21- 2.51), p = 0.003), thrombocytopenia grade 3 or 4 (OR 4.35 (95% CI 1.062-17.827), p = 0.034) and drop in hemoglobin after 2 cycles (OR 1.65 (95% CI 1.09-2.48), p = 0.017). Nearly one fourth of the study population had a delay between two cycles of chemotherapy due to anemia. A median additional cost of Rs 7000 (IQR-Rs 7000 – Rs 14000) was incurred on transfusion.Conclusion: Anemia is a common toxicity associated with dose dense chemotherapy during curative breast cancer treatment leading to delay in treatment and increased cost. Low grade tumor, grade 3 or 4 thrombocytopenia and Grade 2 or higher anemia after 2 cycles of chemotherapy are risk factors for blood transfusions during treatment.

Background The administration of 5-fluorouracil (5FU) in the treatment of gastrointestinal (GI) malignancies is associated with common side effects such as mucositis, diarrhoea, and myelosuppression, which are easily managed with supportive measures and dose adjustments. Cardiotoxicity and neurotoxicity are rare but reversible side effects of 5-FU and are treated with withdrawal of the drug and conservative measures. The presenting symptoms of 5-FU-induced leukoencephalopathy are often confusing and pose a diagnostic dilemma in routine clinical practice. Methods We report a series of five patients with GI malignancies who developed 5-FU-induced leukoencephalopathy. Results All (n = 5) had Naranjo scores of 6–7, predictive of 5-FU-related adverse effects, with clinical and radiological findings suggestive of 5-FU-induced encephalopathy as described in prior literature. The median time to onset of symptoms from initiation of 5FU was 3 days (range: 2–4 days). All patients improved after conservative management with complete neurological recovery. Conclusion Prompt recognition of this rare yet severe adverse effect of 5-FU-based chemotherapy aids early withdrawal of the offending agent (5-FU) and timely initiation of supportive measures and helps plan alternative oncological interventions.

In this retrospective analysis of 36 patients with recurrent ovarian cancer (ROC) treated with platinum pemetrexed doublet ± bevacizumab, the median age was 54.5 years (47-60) and 33 (91.7%) had serous histology. The overall response rate [ORR = complete (CR)+partial (PR) response] was 83.3%. At a median follow-up of 16 months, the median PFS was 13.8 months (95% CI: 10.849-20.580) and median OS 30.6 months, (95% CI: 21.46 months-NR). The incidence of Grade 3/4 anemia, thrombocytopenia, neutropenia and non-hematological toxicity was 19.4%, 3.9%, 16.6%, and 8.3%. Platinum pemetrexed chemotherapy in ROC is safe and effective treatment option.

Background Adjuvant chemotherapy after surgery for gastric cancer improves survival but is difficult to administer due to poor tolerance. Combination chemotherapy with Docetaxel (Taxotere), Oxaliplatin (Eloxatin) and Capecitabine (Xeloda) (TEX) is used in the treatment of advanced gastric cancer. The efficacy and tolerability of this regimen (TEX) post resection of gastric cancer have not been studied. Materials and methods Patients diagnosed with gastric adenocarcinoma, post resection without any prior chemotherapy between July 2007 and May 2011 and treated with TEX regimen administered as T 35 mg/m2 and E 50 mg/m2 on days (d) 1, 8 and X 625 mg/m2 bid (twice daily) on d 1-14 every 21 days were included in this retrospective analysis. Patient's electronic medical records were studied and data on tolerance, progression‑free survival (PFS) and overall survival (OS) was collected. Results Fifty-eight patients were treated with adjuvant TEX chemotherapy, majority 40 (68%) had distal gastric cancer. All patients underwent a D1 gastrectomy, and resection was performed for 44 (75%). Only 14 (24%) patients had more than 15 nodes studied in the resected specimen. Distribution for stages I, II and III is 14 (24%), 30 (52%) and 14 (24%), respectively. After a median follow-up of 40 months, the 3-year relapse free survival was 58% (95% CI: 42-68), and estimated median OS was 71 months (95% CI: 19-123 months). Twenty-three (40%) required dose reduction due to toxicity. Grade 3 or 4 toxicity was recorded for 22 (37%). Half (52%) of patients completed all planned chemotherapy of six cycles. Conclusion Post resection of gastric adenocarcinoma adjuvant triplet TEX chemotherapy is a feasible and effective outpatient regimen. Diarrhoea, neutropenia and neuropathy were the common dose limiting toxicity. Post-surgery only half the numbers of patients are able to complete all planned cycles.

Palbociclib is a cyclin dependent kinase (CDK) 4/6 inhibitor that is indicated in combination with an aromatase inhibitor for first-line treatment of hormone receptor-positive, human epidermal growth factor receptor 2 -negative advanced or metastatic breast cancer. The commonly described side effects of palbociclib are neutropenia, anaemia, thrombocytopenia, fatigue, nausea, stomatitis, alopecia, diarrhoea, decreased appetite, vomiting, asthenia, peripheral neuropathy and epistaxis. However, post approval, increasing use of this drug has revealed another potentially fatal complication, in the form of pneumonitis, especially in the Asian population. The PALOMA 3 trial showed that rates of grade 3 and grade 4 adverse events were modestly higher in Asians than non-Asians, though palbociclib exposure was similar in both races. From this, we could infer that adverse effects of this drug must be monitored more specifically in individual racial populations. We report a patient who developed pneumonitis while on palbociclib and discuss the possible mechanisms and management of CDK 4/6 inhibitor-related lung injury.

Background Human epidermal growth factor receptor 2 (HER2)-positive breast cancer is associated with poor prognosis and access to anti-HER2 treatment is still a challenge in lower-middle income countries. The availability of the biosimilar trastuzumab has improved access by lowering the costs. We report the pattern of use of neoadjuvant ± adjuvant trastuzumab and outcomes in patients with HER2-positive non-metastatic breast cancer treated with regimens incorporating shorter durations of therapy and the use of the biosimilar trastuzumab compared to the innovator. Methods We conducted a retrospective analysis of patients with non-metastatic HER2-positive breast cancer treated with neoadjuvant ± adjuvant trastuzumab (innovator (n = 34 (33%)) and biosimilar (n = 70 (67%)) manufactured by Biocon Biologics) with chemotherapy. Information regarding chemotherapy regimens, duration of trastuzumab use (≤12 weeks and >12 weeks), pathological response (Miller Payne grade), disease free survival (DFS), overall survival (OS) and safety data were collected from electronic medical records. Results A total of 135 patients were analysed with a median age of 51 years (range: 23-82); of these, 57% were postmenopausal, 31.8% were hormone receptor positive and 62.9% had stage III disease. The overall pathological complete response (p-CR) in both breast and axilla increased to 37.6% in patients treated with trastuzumab preoperatively as compared to 22.2% in patients who did not receive any trastuzumab. Patients receiving innovator trastuzumab and biosimilar trastuzumab showed a p-CR of 28.5% and 41.7%, respectively. At a median follow-up of 42 months (range: 3-114), there were 18 relapses and 11 deaths. The 3-year DFS was 87.1% and OS was 92.2%. Cardiac dysfunction developed in 4 of 78 (5.1%) evaluable patients. Conclusion Access to anti-HER2 therapy in the treatment of non-metastatic HER2-positive breast cancer in resource-constrained settings has improved significantly with the availability of the biosimilar trastuzumab. Imbalances in patient profiles at baseline in routine clinical practice led to inconclusive outcomes of ≤12 weeks versus >12 weeks trastuzumab treatment. However, on the basis of historical data, patients could be offered shorter duration of trastuzumab when a standard 1-year treatment of adjuvant trastuzumab is not feasible in resource-constrained settings. The p-CR using the biosimilar trastuzumab in neoadjuvant treatment has been observed to be comparable to the innovator trastuzumab.

Purpose To discuss and reach a consensus on the use of bevacizumab in women with advanced ovarian cancer in Indian settings. Methods An advisory board meeting comprising Indian oncologists was convened to review key literature available on the role of bevacizumab in the management of advanced ovarian cancer. Key recommendations were devised via consensus by the expert panel based on the analysis of available scientific evidence and clinical experience. Results The expert panel recommends the use of bevacizumab in patients with advanced ovarian cancer in first-line settings, as well as in recurrent settings. Conclusion This document summarizes key discussion points and recommendations provided by the advisory panel, which helps guide clinicians on the use of bevacizumab for managing advanced ovarian cancer in the Indian setting. It also acts as a pragmatic tool to assist clinicians in making appropriate treatment decisions with respect to advanced ovarian cancer.

Purpose Primary mediastinal germ cell tumours (PMGCTs) are rare; with limited data available about their outcomes and optimal treatment in the low middle income countries setting. We studied the clinical profile of patients with PMGCT treated at our centre in order to estimate their survival outcomes and to identify prognostic factors affecting the same. Patients and methods Fifty-seven patients with PMGCTs treated between April 2001 and June 2019 were included. Baseline characteristics, details of first line chemotherapy, response rates, toxicity and surgical outcomes were noted. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Results Among 57 male patients (seminoma = 20 and nonseminomatous = 37), the median follow-up was 10 months (range: 1-120 months). For mediastinal seminoma, 9 (45%) and 11 (55%) patients had good and intermediate risk disease, respectively. Nineteen patients (95%) received BEP (Bleomycin, etoposide and cisplatin) chemotherapy. 94.7% had partial responses and median event-free survival was not reached. All patients were alive and disease free at 2 years. For primary mediastinal nonseminomatous germ cell tumours (PMNSGCTs), all patients were poor risk. Thirty-four (91.8%) received BEP/EP chemotherapy as first line. Responses were PRM+ (partial response with elevated markers) in 7 (20.5%) and PRM- in 12 (35.2%). The incidence of febrile neutropenia was 50% and 55.8% in seminole and PMNSGCT, respectively. The median OS was 9.06 months and median PFS was 4.63 months for PMNSGCT. The proportion of patients alive at 1 year and 2 years were 35% and 24.3%, respectively. Conclusion Primary mediastinal seminomas are rarer and have better survival outcomes. Treatment of PMNSGCT is still a challenge and is associated with poorer survival outcomes.

The study aims to analyse patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus with an intent to postulate optimal nodal radiation. A retrospective review of patients who presented to our centre within a 5-year period (2014–2018), with recurrence following sequential neoadjuvant treatment and radical surgery, was conducted in this single-institution study. The patterns of recurrence and duration of disease-free survival were analysed. Twenty-one patients (14 men, 7 women) presented with recurrence, of which 13, 7, and 1 patient(s) had received NACT, NACTRT, or both, respectively. Six patients who did not receive neoadjuvant radiotherapy received adjuvant RT. Among the 10 patients who had nodal recurrence after RT (either neoadjuvant or adjuvant), 6 and 4 patients had in-field and out-of-field nodal recurrences, respectively—the latter were equally distributed within 5 cm and outside 5 cm of the PTV margin. Among the patients who presented with recurrence, more than half had not received neoadjuvant RT (treated in the ‘pre-CROSS era’ or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. Increased regularity of recurrences in the draining nodal region was not noted in this study, but large-scale, prospective, randomised head-to-head comparative trials to determine optimal nodal irradiation in carcinoma oesophagus are required.

To assess the relevance of enlarged cardiophrenic lymph nodes (CPLN) seen on staging CT of ovarian cancer patients. Retrospective cohort study of consecutive patients with primary ovarian malignancy who underwent staging CT between 2013 and 2016. Images were reviewed by two radiologists in consensus. Enlarged CPLN was defined as a short axis diameter ≥ 7 mm. Clinical and imaging findings; management decisions; outcome of cytoreductive surgery and survival were compared between patients with and without enlarged CPLN on staging CT. Enlarged CPLN were found in 42 patients (41.5%) and was significantly associated with higher radiological PCI (p = 0.002); large volume upper abdominal disease (p = 0.001); enlarged lesser omental, periportal and supra-renal para-aortic lymph nodes (p ≤ 0.05); unfavorable sites of disease involvement (p

Neuroendocrine tumours (NETs) of the urinary tract are rare, and the urinary bladder is the the most common primary site. Primary ureteric NET is rarer with under 80 cases reported in the literature thus far. Most of these tumours are of the high-grade small cell neuroendocrine carcinoma subtype, which has a worse prognosis. Neoadjuvant chemotherapy has a proven role in the management of NET of the bladder as it downstages the tumour, which may add to significant recurrence-free survival and overall survival. We report the successful management of a patient with locally advanced small cell neuroendocrine carcinoma of the ureter, who had a pathological complete response after neoadjuvant chemotherapy with etoposide and cisplatin. He subsequently received adjuvant chemotherapy followed by radiation and is recurrence-free at a follow-up of 1 year.

Background Salvage regimens in relapsed/refractory Hodgkin’s lymphoma (HL) differ in their efficacy and toxicity profiles. Gemcitabine (G), vinorelbine (V) and liposomal doxorubicin (GVDoxil) is one regimen with high response rates but has high toxicity and cost. We devised a regimen of GVDex by substituting the more expensive liposomal doxorubicin with the cheaper high-dose dexamethasone (Dex). Patients and methods We analyzed the data of 48 adult and paediatric patients of relapsed/refractory HL who received GVDex as salvage therapy. GVDex was delivered as outpatient once in 3 weeks (Q3 weekly) (G 1000 mg/m2 IV over 30 min on D1, 8; V 25 mg/m2 IV fast infusion on D1, 8; Dex40 mg PO D1-4) for 2–3 cycles. We present the overall response rate, toxicity, progression-free (PFS) and overall survival (OS) from the time of start of GVDex. Results Forty-eight patients [median age: 24 years (5–63)] received GVDex [(median cycles:3(1–6)] in this period. Median time from diagnosis to the first relapse was 18.9 (2–119) months. Overall response rate [ORR = complete (CR)+partial (PR)] was 63%. Eleven (23%) patients developed febrile neutropenia. After a median follow-up of 20 months, the Kaplan-Meier estimates of patients alive and progression-free at 24 months were 60% and 49%, respectively. Conclusions The response rates with GVDex were comparable to those reported with GVDoxil when used as a first-line salvage regimen in relapsed/refractory HL. It was an effective regimen even in patients who failed 2 lines of therapy for HL.

e19519 Background: Gemcitabine, vinorelbine and liposomal doxorubicin (GVD) is an effective regimen in relapsed/refractory Hodgkin’s lymphoma (RRHL). Conventional second-line chemotherapy is still required as the cost of immunotherapy and antibody-drug conjugates are prohibitive to Indian patients. We report the results of a phase II, open-label, single-arm, single centre interventional study in RRHL where dexamethasone replaced liposomal doxorubicin. Methods: Adult patients (≥18 years) with RRHL at first or second relapse were included. GVDex was delivered as outpatient once in 3 weeks (Gemcitabine 1000 mg/m2 IV over 30 min on D1,8; Vinblastine 25 mg/m2 IV fast infusion on D1,8; Dexamethasone 40 mg PO D1-4) for two cycles followed by interim PET CT assessment by Cheson’s criteria and Deauville scoring. The primary endpoint was the objective response rate (ORR = complete response + partial response). The sample size was calculated using Fleming’s 2-stage model (α error: 0.05 and power: 0.8). Twenty patients were required in the first stage. If there were ≥16 responses, the null hypothesis would be rejected and the study stopped. Results: Between May 2016, and December 2020, 26 patients with RRHL were screened, and 20 were enrolled: primary resistant HL-8 patients (40%) and relapsed HL- 12 patients (60%). The median age was 35 years (range:20-52). Six patients (30%) presented with limited stage and 14 patients (70%) with advanced stage HL at relapse. GVdex was delivered as a first salvage regimen in 18 patients (90%) and second in 2 patients. After 2 cycles of GVDex, 16 (80%) had responded [partial response: 12 (60%); complete response: 4 (20%)]. Median number of cycles of GVDex: 3 (range: 1-4). Five patients (25%) required dose reductions due to chemotherapy-related toxicities. The median duration of objective response was 13.4 months. Eleven patients (55%) underwent high-dose chemotherapy supported by autologous stem cell rescue. After a median follow-up of 25 months (95% CI: 5.9-44.5), the median progression-free survival (PFS) was 24.7 months, and the median overall survival (OS) has not been reached. The estimated 2-year PFS was 44%, and the 2-year OS was 79%. The most common treatment-related adverse events were anemia (100%), neutropenia (70%, 14/20) and fatigue (70%, 14/20). Grade 3 or 4 treatment-related AEs occurred in 14 patients (70%). Grade ≥3 neutropenia occurred in 9 patients (45%) and febrile neutropenia in 3 patients (15%). Serious adverse events were reported in 3 patients (15%). One patient developed Ficat and Arlet classification stage III avascular necrosis of the femoral head. One patient died due to suspected COVID-19 pneumonia (non-neutropenic fever) before cycle 2 of chemotherapy. Conclusions: GVDex it is an effective salvage regimen with acceptable toxicity in patients with RRHL. Clinical trial information: CTRI/2017/04/008361.

Background Malignant tumors in neonates are rare. Case characteristics A tumor was detected in the left biceps of a 3-day old neonate. Tumor biopsy and molecular study confirmed the diagnosis of synovial sarcoma. The child received multi-modality treatment with surgery and chemotherapy. Outcome The child is disease-free on follow-up period of 12 months. Message Synovial sarcoma can rarely occur in a neonate.

INTRODUCTION: Traditional platinum-based salvage regimens like DHAP, ICE are effective in relapsed Hodgkin's lymphoma (HL), but are more toxic. Gemcitabine based regimens are equally effective in salvage of lymphomas, but are less toxic and allow better stem cell collection for subsequent high dose therapy (HDT). There is limited data on the usefulness of gemcitabine based salvage regimens after the failure of salvage therapies like DHAP and ICE. At our center, we used a combination of gemcitabine, vinorelbine and dexamethasone (GVDexa), a non-platinum containing regimen in those patients who failed DHAP/ ICE based salvage treatment. METHODS: The records of patients with relapsed and refractory Hodgkin's lymphoma, who were treated with GVDexa, were reviewed. The regimen consisted of Gemcitabine 1000mg/m2 IV (D1,8), Vinorelbine 25mg/m2 IV (D1,8) Dexamethasone 40mg oral (D1-4) given as outpatient. It was given for 2-3 cycles until best response or till the patient underwent HDT. RESULTS: Between July 2010 to Jun 2015, 25 patients received GVDexa. The median age was 23 years (Range: 11 to 45 yrs) and 64% were males. Baseline characteristics are summarised in Table 1. Twenty-one patients (84%) had previous exposure to salvage therapy with DHAP/ ICE and GVDexa was given as third line treatment. The overall response rate was 48% (12/25) with complete response in 20% (5/25) and partial response in 28% (7/25). Toxicity: A total of 61 cycles [Median: 2 (Range: 1-6)] were delivered among 25 patients. Grade 3/4 haematological toxicities (neutropenia and thrombocytopenia) occurred in 9/61 (14.7%) cycles and febrile neutropenia occurred in 2 (3.2%) cycles. Grade 3/4 non-haematological toxicities were rare (paralytic ileus in 1 patient). There were no toxic deaths. Stem cell collection: Stem cell harvesting for HDT was attempted in 12 patients and was successful (> 2 million CD34 positive cells/kg) in 8 (67%) patients. Seven of these patients successfully completed HDT. Two patients who failed stem cell collection underwent reduced intensity conditioning allogeneic transplant. CONCLUSIONS: GVDexa, when used as third line therapy in relapsed and refractory HL shows promising response rates, with minimal toxicity. The high response rates achieved despite failure of first line platinum based salvage, points to the potential usefulness of this regimen as first line salvage therapy in refractory HL. GVDexa could emerge as a safe and effective non-platinum containing alternative regimen for second-line therapy in HL. Table 1. Baseline characteristics (N=25) PARAMETER Number (Range/Percentage) Age (median, range) 23 yrs (10 to 45 yrs) Male sex 16 (64%) Prior exposure to DHAP/ICE chemotherapy 21 (84%) Previous lines of chemotherapy (median, range) 2 (1 to 4) Time from 1st diagnosis to relapse (median, range) 31.5 months (4.3 to 153.7 months) Primary progressivea/refractory 13 (52) Stage III/IV at relapse 20 (80) Haemoglobin < 10g/dL at relapse 12 (48) a. Progressed within 3 months of completion of first line chemotherapy Disclosures No relevant conflicts of interest to declare.

Introduction: We performed retrospective analysis of 106 patients with lung cancer for which formalin-fixed paraffin-embedded tissues was available. Their epidermal growth factor receptor (EGFR) mutation status and treatment outcomes are described. Materials and Methods: All patients with confirmed non - small cell lung cancer (NSCLC) during Jan 2008 to Dec 2010 were included. EGFR sequencing was performed with ABI PRISM 310 genetic analyzer. Results: Forty-two (39.6%) patients had mutation in one of the four exons characterized. Patients whose EGFR mutational status was not available at presentation before the start of treatment were started on chemotherapy, n = 46 (43.39%). If EGFR mutational analysis was available and mutations were present, the patients were started on either upfront tyrosine kinase inhibitor (TKI), n = 15 (14.15%) or if on chemotherapy arm were allowed to finish six cycles and then start with maintenance TKIs, n = 26 (24.52%). The median progression free survival for patients with and without mutations was 11 months (95% CI,7-14) and 9 months (95% CI,7-10) respectively. A median PFS of 14 months (95%CI, 12-16) was seen in the mutation-positive group that received both chemotherapy followed by switch maintenance with TKIs versus 8 months (95%CI, 7-8 months) in the group that received only TKI. Conclusion: The prevalence of EGFR mutations in this population of NSCLC patients was 39.6% with exon 19 mutation being the most common. The observed benefit of addition of chemotherapy over TKI in EGFR mutation-positive group raises the question, can we offer the therapy of chemotherapy-TKI combination to EGFR mutation-positive lung cancer patients as shown in the present study.