Clinical Assistant Professor, Department of Medical Oncology, Cancer Institute, Amrita Institute of Medical Sciences, Ponekkara PO - 682041, Kochi, Kerala, INDIA
May 2011 till date - Clinical Assistant Professor, Department of Medical Oncology, Amrita Institute of Medical Sciences, Kochi
April 2008 – April 2011- Senior Resident in Medical Oncology, Department of Medical Oncology, Amrita Institute of Medical Sciences, Kochi
June 2006 – April 2008 - Lecturer / Assistant Professor of Medicine, Department of Medicine, Christian Medical College and Hospital, Ludhiana
July 2003 – May 2006 - Consultant Physician and In-charge, Unit of Internal Medicine, Christian Hospital, (Emmanuel Hospital Association), Chhatarpur Post and District, Madhya Pradesh, India
January 2003 - June 2003 - Lecturer / Assistant Professor of Medicine, Department of Medicine, Christian Medical College and Hospital, Ludhiana
January 2000 – December 2002 - Junior Resident in Internal Medicine, Christian Medical College and Hospital, Ludhiana, Punjab
January 1998 – December 1999 - Junior Medical officer, Christian Hospital, (Emmanuel Hospital Association) Kachhwa, Mirzapur District, Uttar Pradesh, India
June 1992 – December 1997 - MBBS Undergraduate Training, Christian Medical College and Hospital, Ludhiana, Punjab
MEMBER ************ American Society of Clinical Oncology (ASCO) European Society of Medical Oncology (ESMO) Indian Association of Cancer Research (IACR) The Association of Physicians of India (API) Indian Academy of Clinical Medicine (IACM) Indian Society of Medical and Pediatric Oncology (ISMPO)
Abstract: Common differential diagnosis of lung and hilar opacity includes infectious pathology or a mitotic lesion. Behcetâs disease (BD) is a rarely diagnosed disease in Indian subcontinent. BD is a multisystem inflammatory disorder that presents with recurrent orogenital ulceration, uveitis, and erythema nodosum. We present here the case of a patient who presented with recurrent hemoptysis with radiological picture of hilar mass, during the evaluation of which the diagnosis of BD was established.
Abstract: Carcinosarcomas are rare, mixed, malignant neoplasms which are composed of both carcinomatous and sarcomatous elements, showing distinct immunohistochemical and ultra structural features. While the uterus is one organ where they are encountered most often, some cases have been diagnosed in other organs, including the pancreas. We have reported a case of pancreatic carcinosarcoma which was diagnosed in our institute and have reviewed the epidemiology and the clinico-pathological characteristics of all cases of carcinosarcoma of the pancreas which have been reported worldwide.
Abstract: Systemic lupus erythematosus (SLE) is a common disease with myriad presentation. Aplastic anaemia is occasionally associated with this disorder; however, a simultaneous diagnosis of aplastic anaemia with SLE on presentation is unusual. We present here, probably the first reported case of simultaneous presentation of aplastic anaemia with florid features of SLE.
Abstract: In India, a clinical and/or a laboratory diagnosis of hypereosinophilia is very common and is usually attributed to parasitic infestations (viz helminthiasis and filariasis) or atopy. The treatment usually includes deworming or antifilarial drugs in the filaria endemic regions. We report here, a case of hypereosinophilic syndrome in a middle-aged man, who presented with features which mimicked asthma with eosinophilia that did not respond to the routine treatment measures. He was found to have a FIP1L1-PDGFR-α mutation and he improved on treatment with the small molecule, tyrosine kinase inhibitor, Imatinib that is commonly used in patients with malignant diseases of haematological origin.
Abstract: An elderly man, with no comorbidity, presented with rapidly accumulating left pleural effusion. He also had generalized adenopathy. Pleural fluid cytology showed exudative pleural effusion with eosinophilia. Supraclavicular lymph node biopsy was reported as amyloid. On further investigation he was found to have kappa-light chain multiple myeloma. The final diagnosis was eosinophilic pleural effusion in a patient with multiple myeloma.
Abstract: Hepatitis A is a common endemic infection in a country such as India where a large majority of population is unimmunized and is exposed to unhygienic food, water, and living conditions. Most of these patients develop a classic form of hepatitis A with jaundice, abdominal pain, fever, and diarrhea. However, a few patients develop rare extrahepatic and hematological complications. A case of autoimmune thrombocytopenic purpura with acute hepatitis A is presented here.
Abstract: Sister Joseph nodule is a metastatic umbilical lesion secondary to a primary malignancy of any viscera. It can be a presenting symptom (a sign of undiagnosed malignancy) or a symptom or sign of progression or recurrence in a known case. Its incidence is 1%â3% of all intra-abdominal or pelvic malignancies. Here, we present 4 such cases, with Sister Joseph nodule as a finding of presentation in a case of gallbladder carcinoma, progression in a case of malignant gastrointestinal stromal tumour, recurrence in a case of ovarian carcinoma, and presentation in a case of rectal carcinoma.
The clinicopathologic features of all 4 patients are discussed, and the related literature is briefly reviewed.
Abstract: Behçet's disease (BD) is a multi-system inflammatory disorder which presents with recurrent orogenital ulceration, uveitis, and erythema nodosum. Medium vessel vasculitis of upper limb is extremely rare and it is only reported in patients with Behçet's disease on long follow up. Mean duration from diagnosis of disease to development of vasculitis is 5.8 years. We present a patient who presented with gangrene of fingers with absent radial pulse and during course of his illness he developed features of Behçet's disease. Diagnosis was established by clinical features and histopathology and patient was treated with steroids and colchicine.
Abstract: Background: The incidence of MM in India is 0.5-1.2 per 100000 according to hospital based data. Lenalidomide is a safer and more effective alternative than Thalidomide in the management of myeloma. Both inhibit the production of TNF âα by enhancing the degradation of TNF α mRNA. The frequency of individual polymorphisms in TNF âα may correlate with the response to therapy.
Objectives: The aim of this study was to assess the efficacy and safety of lenalidomide plus dexamethasone in patients with previously untreated MM. In addition we evaluated for the SNPs in TNF α in the patients.
Methodology: It is an ongoing study, and data from May 2009 â June 2010 is presented. 28/50 patients were eligible for this study. The treatment regimen consisted of 25 mg lenalidomide daily for 3 weeks every month for 6 cycles. In addition, 40 mg dexamethasone was given orally every week for 6 months, following which reevaluation was performed. The median duration of follow up is 8 months. One patient was lost to follow up in the third month but is included for analysis. We evaluated in the DNA from peripheral blood for 5 single nucleotide polymorphisms (-238 G/A, -308 G/A, -857 C/T, -863 C/A, 1031 T/C) in the promoter region of TNF α by PCR-RFLP.
Results: Patients had IgG (13/28); IgA (6/28); light chain (9/28) subtypes of myeloma. Fifteen out of twenty four (62.5%) patients had an abnormal karyotype. Trisomy and monosomy of chromosome 15 (30%) were the most common abnormality. Of 26/28 evaluable patients; 9/26 achieved sCR, 10/ 26 achieved CR, 6/26 had PR and 1/26 had PD.
The preliminary results show that in 15/28 patients, the allele frequency for individual SNPs was 6.66% (-238), 13.33 % (-308), 93.33% (-857), 20 % (-863) and 66.6% (-1031). The allele frequency of -857 (C/T) and -1031 (T/C) is significantly higher than the control (10.97% and 33.4% respectively) frequency in India (Ï2 = 119.00; d.f = 1; p<0.0001; OR=113.65; 95% CI = 24.64 â 723.58) and Ï2 = 9.98, d,f.= 1; p=0.0016, OR = 3.64; 95% CI = 1.55-8.68 respectively).
Conclusion: Lenalidomide and short course Dexamethasone is a safe and effective regimen in newly detected MM. The complete response (73% - 19/26) rate in Indian patients is significantly higher than that reported in the western literature (38%). The polymorphism in the -857 region of the promoter seems to be highly significant in MM patients when compared with that of the controls and we need to evaluate if -857 region has a functional role in the expression of TNF-α.
Abstract: Backgound: The recent discovery of G-T point mutation (V617F) in the JAK2 gene on chromosome 9 in most patients of Myeloproliferative disorders has revitalized the diagnostic criteria of this group of disorders. The JAK2 V617F point mutation makes the normal hematopoietic progenitor cells hypersensitive to thrombopoietin, erythropoietin, and myeloid progenitor cells, leading to trilinear hematopoietic myeloproliferation. Patients who have not been treated for the diseases are at great risk of morbidity and mortality as a result of thrombotic/ haemorrhagic events. Studies have reported varying frequency of this point mutation with respect to polycythemia rubra vera (PRV) in different ethnic groups. There is a paucity of data from India on this regard.
Methods: The study was done on patients attending the out patient clinic of oncology and hematology at Amrita Institute of Medical Sciences, Kochi. JAK2 V617F mutation analysis by PCR- RFLP was done in 46 patients diagnosed with PRV. Clinical and biochemical measurements were done using standard protocols.
Results: Of the 46 patients studied, 32 (69.6%) patients were positive for JAK2 V617F mutation. Further, JAK2 V617F mutation was also associated with higher leucocyte(p=0.002), erythrocyte(p=0.043) and platelet count (p=0.006). The JAK2 V617F mutation was also associated with higher rates of stroke.
Conclusion: The significant finding of our study is that the frequency of JAK2 V617F mutation is lesser in Asian Indian patients with PRV compared to other ethnic groups. Our study supports the evidence that the JAK2 V617F mutation may be associated with an aggressive phenotype with more symptomatic presentation and higher rates of stroke.
Abstract: This is an ongoing study. 23 patients have been enrolled. 6/23 have completed six months treatment, 10/23 have completed three months, 4/23 two months and 3/23 one month each. 20/23 patients are evaluable for response and toxicity. Patients had IgG (10/23); IgA (4/23); Kappa (6/23) and Lambda (3/23). Five patients had normal cytogenetics. Four patients had aneuploidy with three having trisomy and one had monosomy of chromosome 15. Toxicity observed were as follows: 1/23 patient had grade 4 neutropenia / thrombocytopenia, 1/23 had acute CVA, 2/23 had grade 3 hypocalcemia, 5/23 had grade 1-2 urticaria and 4/23 had grade 1-2 constipation (4/23). None had DVT, peripheral neuropathy or sedation. Among 15 patients who completed at least three cycles of treatment, 11/15 achieved CR, 4/15 had PR. There were no deaths recorded.
Conclusion: Lenalidomide and Short course Dexamethasone is a safe and effective regimen in newly detected Multiple Myeloma. The complete response (73% - 11/15) rate in Indian patients is significantly higher than that reported in the western literature (38%).
Abstract: BACKGROUND â Multiple myeloma is a clonal plasma cell malignancy that accounts for slightly more than 10% of all hematological cancers. The Indian data on epidemiology of myeloma is mostly hospital based and is scanty. The reported incidence of multiple myeloma in India ranges from 0.5 to 1.2 per 100,000 according to hospital based data. Lenalidomide / Dexamethasone is now being found to be a safer and more effective alternative than combination of Thalidomide and Dexamethasone in newly diagnosed myeloma. The aim of this single institutional single arm study was to assess the efficacy and safety of lenalidomide plus dexamethasone treatment in newly diagnosed multiple myeloma patients.
PATIENTS AND RESULTS â This study was conducted from May 2009 till July 2010. Fifty patients were evaluated and 28 eligible patients were enrolled. The median duration of follow up is 8 months (range 3 â 14 months). One patient was lost to follow up in the third month but is included for analysis. Clinical, laboratory and radiological data for all patients are available. All patients with at least three months of follow up from the start of treatment have been included in the analysis. Patients had IgG (13/28); IgA (6/28); Kappa (6/28) and Lambda light chain (3/28) subtypes of myeloma. Fifteen (62.5%) patients had an abnormal karyotype and the remaining nine (37.5%) patients had a normal karyotype. Most common abnormality was in chromosome 15. Ten (35.7%) patients experienced grade III or higher non-hematologic toxicity and three (10.7%) had grade III or higher hematologic toxicity. One patient had thrombo-pulmonary embolism and was taken off the study at 2 months. None had DVT, peripheral neuropathy or sedation. One death was recorded. Of remaining 26 evaluable patients for response, 9/26 achieved sCR, 10/26 achieved CR, 6/26 had PR and 1/26 had PD.
CONCLUSION â
Lenalidomide and Short course Dexamethasone is a safe and effective regimen in newly detected Multiple Myeloma. The complete response (73% - 19/26) rate in Indian patients is significantly higher than that reported in the western literature (38%). The reasons for this higher response rate need to be addressed by further research.
