Dr. Alok Gupta presents two interesting clinical cases. Case 1 involves a 59-year-old woman with relapsed ovarian clear cell carcinoma who had progressed through five lines of therapy. She was started on pazopanib, a targeted therapy, and showed an ongoing partial response for over a year. Case 2 involves a 58-year-old woman presenting with esophageal cancer who was also found to have synchronous colorectal cancer. She received neoadjuvant chemotherapy, followed by surgery to remove both cancers, and remains disease-free after two years of follow up and adjuvant chemotherapy. Both cases demonstrate successful treatment approaches for difficult cancer cases.

1. Interesting Clinical Cases
Dr Alok Gupta
MD, DM,
Consultant Medical Oncologist
Max Super Speciality Hospital, Saket
Max Hospital, Gurgaon
Ex-Asst. Professor, AIIMS, New Delhi

2. Case 1
Targeted Therapy in a patient
with Relapsed/Refractory
Advanced Ovarian Clear Cell
Carcinoma

4. Outcome in Ovarian Clear Cell Carcinoma

5. Outcome in Ovarian Clear Cell Carcinoma

6. Presentation
 59 /Lady
 No family history of breast and ovarian cancer
 Diagnosed with Ovarian clear cell carcinoma in
March 2014.
 She underwent total abdominal hysterectomy
with bilateral salpingo-ophorectomy at Kolkata.
 Thereafter, went to Singapore for treatment.

7. Presentation
 Evaluation at Singapore in April 2014 revealed FDG avid
mass in left pelvis 1.5 x 2.2 cm.

8. Treatment
 Started on Standard Chemotherapy with Paclitaxel and Carboplatin.
 Pet CT done 3rd June 2014 showed FDG avid mass in left adnexa
has increase in size 4.0 x 4.5cm.

9. Treatment
 She Underwent debulking surgery on 10thJune 2014.
The mass was consistent with a clear cell carcinoma.
 Second Line chemotherapy with Liposomal Doxorubicin
was started after surgery.

10. Treatment
 PET CT post three cycles of Doxil showed recurrence of pelvis mass now measuring
5.0 x 6.0cm.
 There were also new FDG-avid peritoneal nodules in the posterior to midline scar, left
perivascular region, and right internal iliac region, and right pelvis, all consistent with
recurrence in the pelvic region.

11. Treatment
 Third line chemotherapy with Gemcitabine and Avastin
(Bevacizumab) for 3 cycles

12. Treatment
 Fourth line chemotherapy with Irinotecan with capecitabine was started in
March 2015
 Disease progression in May 2015
 Fifth line therapy with Everolimus (mTOR inhibitor) was started in June
2015.
 Disease progression in September 2015.
 Patient was sent back to India in September 2015 after there was disease
progression after 5 LINES of Therapy.

13. Presentation in India
 Very poor general condition
 Sepsis with pan-cytopenia
 Admitted in ICU for 1 month in Kolkata
 Disease progression on Everolimus
 At this point, all cancer treatment was stopped
and patient was treated for sepsis.

14. Treatment in INDIA
 Came to us for second opinion in Nov 2015
 Literature search was done

15. Molecular Pathways in Pathogenesis of Cancer

16. Proteins highly expressed or activated in clear cell
carcinoma

17. Targeted Therapies: The Revolution

18. Treatment
 Patient was started on Pazopanib on 16 Nov 2015

19. July 2016
November 2016

20. Lessons Learnt

21. Synchronous colorectal cancer in a patient presenting
with oesophageal cancer
Case 2

22. Presentation
 58 year female
 Comorbidities: hypertension and type-2 diabetes
mellitus
 No history of addictions
 No family history of cancer
 Presented with dysphagia to solid food and
weight loss of five kg over last two months.
 No lower GI symptoms

23. Work Up
 CT Thorax-Thickening of lower third oesophagus
extending into GE junction and proximal
stomach.
 Upper GI scopy-ulceroproliferative lesion from
33 cm till 38 cm with involvement of GE junction
and extending to cardia.
 Biopsy-poorly differentiated adenocarcinoma

24. Work Up
 PET-CT- metabolically active disease at lower
third oesophagus and GE junction. Also showed
increased uptake in splenic flexure of colon.
 Colonoscopy-ulceroproliferative lesion at splenic
flexure with mild luminal compromise.
 Biopsy-moderately differentiated
adenocarcinoma.

25. PET/CT

26. (a) (b) (c)
Oesophagus tumor showed groups and cords of carcinoma cells(a & b), with focal gland formation(c)
Tumor in the colon was a typical colonic-type of adenocarcinoma.(a & b)
(a) (b)
Oesophageal and Colonic Tumor were different
histopathologically

27. Treatment
 6 cycles of FOLFIRI regimen (5- fluorouracil,
leucovorin and irinotecan) as neoadjuvant
chemotherapy.

 Repeat PET-CT showed partial metabolic and
morphological regression of circumferential
thickening in both lower third oesophagus and
splenic flexure of colon.

28. PET-CT imaging showing active disease in lower third oesophagus and splenic flexure of
colon pre(a) and post(b) neoadjuvant chemotherapy
(a) (b)

29. Treatment
 Patient underwent transhiatal oesophago-
gastrectomy and left hemicolectomy (R0
resection).
 Then patient received adjuvant chemotherapy
with six cycles of FOLFIRI regimen.

30. Presently on Surveillance
 The patient was then kept on regular followup
with repeat CEA levels, upper and lower
gastrointestinal endoscopy and scans planned
at every six months for two years.
 After two years of followup the patient remains
asymptomatic and negative for disease relapse
on investigations.

31. Lessons Learnt

32. Thank You
Dr Alok Gupta MD, DM,
Consultant Medical Oncologist
Max Super Speciality Hospital, Saket
Phone No. 9167164364
Email: alokgupta16@yahoo.co.in