A dosemetric and radiobiological impact of VMAT and 3DCRT on lumbosacral plexuses, an underestimated organ at risk in cervical cancer patients.

Background: The purpose of this study was to evaluate dosimetric and radiobiological difference between volumetric modulated arc therapy (VMAT) and 3-dimensional conformal radiotherapy (3DCRT) in organ at risk (OAR) lumbosacral plexus (LSP) in cervical cancer patients. Materials and methods: 30 patients of cervical cancer who were treated using 3DCRT or VMAT along with chemotherapy followed by brachytherapy were enrolled. LSP was delineated retrospectively. Dosimetric and radiobiological difference was evaluated. Patients were followed for radiation induced lumbosacral plexopathy (RILSP). Results: Median follow-up was 12 months (3-16 months). 53.3% of patients were treated by 3DCRT and 46.7% by VMAT. The mean (±SD) LSP volume: 119.03 ± 15 cm3. The mean volume percentages (%) of the LSP: V5, V10, V20, V30, V40, V50, V55, and V60 were 100%, 99.8%, 99.2%, 94.3%, 84.03%, 59.7%, 0%, 0%, respectively. All patients received doses to the LSP in excess of 50 Gy, one patient received 55 Gy. A statistically significant difference was observed in the median value of V20, V30, V40, V50, D50, P2, P4, P7, P8, P9, and P10 across two different techniques of radiotherapy - VMAT and 3DCRT. None of the patients presented with RILSP. NTCP value was less in VMAT plans compared to 3DCRT, which is also statistically significant. Conclusion: RILSP is a rare and often refractory complication of pelvic radiotherapy. Advance radiotherapy technique with proper OAR delineation and constraint can prevent the occurrence of RILSP. VMAT has potential benefits for the probability of dose reduction in LSP. Further studies are required focusing on dose distribution in LSP-OAR and radiotherapy modality.

A Tie2-Notch1 signaling axis regulates regeneration of the endothelial bone marrow niche.

Loss-of-function studies have determined that Notch signaling is essential for hematopoietic and endothelial development. By deleting a single allele of the Notch1 transcriptional activation domain we generated viable, post-natal mice exhibiting hypomorphic Notch signaling. These heterozygous mice, which lack only one copy of the transcriptional activation domain, appear normal and have no endothelial or hematopoietic phenotype, apart from an inherent, cell-autonomous defect in T-cell lineage development. Following chemotherapy, these hypomorphs exhibited severe pancytopenia, weight loss and morbidity. This phenotype was confirmed in an endothelial-specific, loss-of-function Notch1 model system. Ang1, secreted by hematopoietic progenitors after damage, activated endothelial Tie2 signaling, which in turn enhanced expression of Notch ligands and potentiated Notch1 receptor activation. In our heterozygous, hypomorphic model system, the mutant protein that lacks the Notch1 transcriptional activation domain accumulated in endothelial cells and interfered with optimal activity of the wildtype Notch1 transcriptional complex. Failure of the hypomorphic mutant to efficiently drive transcription of key gene targets such as Hes1 and Myc prolonged apoptosis and limited regeneration of the bone marrow niche. Thus, basal Notch1 signaling is sufficient for niche development, but robust Notch activity is required for regeneration of the bone marrow endothelial niche and hematopoietic recovery.

Comparison of clinical indices with halitosis grading in chronic periodontitis: A randomized control trial.

Background: Oral malodor is a major periodontal complaint, but the best method for assessing the halitosis grade is still undefined. The primary objective of the study was to detect the halitosis grade in the exhaled breath using the three distinct techniques and to compare the readings with different clinical indices to find out the best method of halitosis grading. Materials and Methods: A total of 90 patients with chronic periodontitis having oral malodor were included in the study. The subjective assessment of the exhaled breath (halitosis grading) was done by three different methods; using a handheld portable Tanita FitScan sulfide monitor, by Halitox toxin assay, and by organoleptic (Sniff test) method. The findings were then compared with the clinical parameters of poor oral hygiene like plaque index (PI), gingival index (GI), gingival bleeding index (BI), and pocket depth (PD) to detect the best method of halitosis grading. Results: The mean age of the patients included was 38.23 ± 8.83 (mean ± standard deviation) years. The median value of halitosis grading as obtained by Tanita FitScan was 3.0 (95% confidence interval as 2 and 4) which was then compared with clinical indices (PI, GI, BI, and PD) and the results were statistically significant (P < 0.05), whereas the other two techniques of halitosis grading gave insignificant results. Conclusion: The results confirmed that the halitosis grading done using Tanita FitScan sulfide monitor is more appropriate with respect to clinical indices when compared with the other two techniques.

A rare case of benign metastasizing leiomyoma at vertebrae.

ABSTRACT: Benign metastasizing leiomyoma (BML) is a rare disease that usually occurs in women of reproductive age, with a history of uterine leiomyoma treated with hysterectomy. This may present as lesions in lungs, lymph nodes, bones, brain, mediastinum, and soft tissues. However, the most commonly affected site is the lung. Here is a case report of a patient who presented with BML at vertebral body with distant metastasis to lungs, brain, and bones. A 37-year-old female, with no known comorbidities, presented with pain in the upper back, urinary and bowel incontinence, and weakness in the bilateral lower limbs. Radiological, multiple metastases were present at D2 and D9 vertebral bodies, multiple nodular lesions were present in the lungs, and solitary lesion was found in the right frontal lobe of the brain. Histology proved it to be of myoepithelial origin with low Ki-67 index. The treatment in this case was based on hormone production suppression and radiotherapy, with no signs of progression at follow-up.

Upfront debulking surgery or delayed surgery after neoadjuvant chemotherapy for advanced-stage epithelial ovarian cancer: Comparison of survival from a noncancer center in India.

BACKGROUND: In advanced-stage epithelial ovarian cancer (EOC) standard of care is upfront debulking surgery (UDS) followed by adjuvant chemotherapy. Interval debulking surgery after neoadjuvant chemotherapy(NACT-IDS) is a reasonable alternative. METHODS: This study was a retrospective review of patients of Stage III/IV EOC treated either by UDS or NACT-IDS between January 2016 and December 2018 to report the comparison of progression-free survival(PFS) and overall survival(OS) of patients with advanced-stage EOC treated with either UDS or NACT-IDS. RESULTS: Out of 50 patients, 19 (38%) underwent UDS, and 31 (62%) received NACT. The mean follow-up duration was 27.7 months. No gross residual disease was achieved in 52.6% of the UDS group and in 70.4% of the NACT-IDS group. The median PFS of 20 and 30 months was observed in the UDS and NACT-IDS groups, respectively (log-rank P = 0.054). The median OS was 36 months in the NACT-IDS group and could not be reached in the UDS group (log-rank P = 0.329). Only residual disease was significantly associated with survival (hazards ratio 3.03, 95% confidence interval: 1.19-7.74) on multivariate Cox regression analysis. CONCLUSIONS: In advanced-stage EOC, the survival outcomes of NACT-IDS are comparable with those of UDS. Apart from the patient-specific parameters, the decision for UDS or NACT-IDS should take in account the expertise of the surgeon and the institutional capacity as a whole.

Hepatocellular Carcinoma (HCC) in North-Western India: A Retrospective Study Focusing on Epidemiology, Risk Factors, and Survival.

BACKGROUND: Hepatocellular carcinoma (HCC) is an aggressive tumour with unpredictable outcome. It is fourth most common cause of cancers in India. However, information on HCC is inadequate in India. Therefore, the purpose of study is to determine overall survival for patients diagnosed with HCC and association between various predictive factors and survival. METHODS: Retrospectively 59 patients of HCC presenting to the radiotherapy out-patient department of our institute from April 2015 to April 2018 were included in the study. RESULTS: The median overall survival (OS) was 5 months ranging from 0 to 13 months. Majority of patients were in advance stage (III/IV). All patient died by 13 months. None of the possible predictive factors were found to be significantly associated with survival (p > 0.05) by univariate analysis. However, age < 59 years, male gender, KPS ≤ 60, AFP ≥ 400, cirrhosis, multifocality, tumour size > 10 cm, advance stage (IIIB/IV), Child-Pugh score B/C, CLIP score ≥ 4, and raised bilirubin level had poorer survival compared to other predictive factors. Median survival was better in patient treated with TACE followed by sorafenib + palliative care group (9 months) then sorafenib + palliative care and palliative care alone group (5 and 4 months respectively). Although results were not statistically significant (p = 0.133). Amongst all possible variables, highest hazard was found with multifocal lesion (2.058) and results were statistically significantly (p = 0.045, 95% confidence interval: 0.922 to 4.590) as compared to unifocal lesion with median survival period of 7 vs 9.5 months by Kaplan-Meier survival curve analysis using log rank test. CONCLUSION: Multifocality was independent predicator for poor survival in HCC. Further clinical studies are necessary to improve the outcomes of patients with high risk features.

Assessment of knowledge, attitude, practices and distress level of cancer patients in COVID-19 pandemic: A cross-sectional study.

The diagnosis and treatment of cancer can be an extremely stressful experience for the patient. COVID-19 pandemic has further created an environment of stress and anxiety amongst cancer patients. A cross-sectional study was conducted from March 2020 to May 2020 using google forms to assess the knowledge, distress level, practices, and attitude toward the COVID-19 pandemic in cancer patients. It was observed that the females and elderly patients (> 55 years) were more knowledgeable about the COVID-19 pandemic. Also, females were more prone to emotional stress compared to males. While the younger age group (18-35 years) had a more hard time in dealing with family-related issues compared to other age groups. Therefore, the younger age group (18-35 years) and female gender being more prone to distress, warrant more attention from health care staff and caretakers. Moreover, the study highlights the need for mental and general health screening and intervention to balance the oncological care and COVID-19 situation.

Awareness of an Primitive Art for Treating Otological Diseases in Present Covid-19 Scenario: Need of the Hour.

In current scenario of Covid-19 pandemic spread of virus via aerosol generating procedures has become a special concern in otorhinolaryngology community. Motive of this study is to spread awareness of an ancient forgotten method of performing mastoidectomy through which risk of virus infection can be greatly reduced among otologic surgeons. Retrospective Observational study. Three patients of chronic otitis media with complication were operatively intervened with combined approach of otorhinolaryngology and neurosurgeons. Mastoidectomies were performed without drilling. Instruments used were small, medium and large size gouge, chisel and hammer, curettes, kerrison punches and other microscopic ear instruments. All three patients recovered well without any residual disease or cavity problems. Referring ancient practices like above in this COVID era may prove an important tool in addressing surgical urgencies while combating transmission risks at the same time. One should be vigilant and versatile in surgical techniques in order to serve the needy and save the saviours simultaneously.

Mucinous cystic neoplasm of the liver (MCN-L): a rare presentation and review of the literature.

Mucinous cystic neoplasms of the liver (MCN-L, (previously referred to as cystadenomas or cystadenocarcinoma) are rare cystic tumors that occur within the liver parenchyma, or less frequently, in the extrahepatic bile ducts. They are reported to account for <5% of all liver cysts. The differential diagnosis of MCN-L includes intraductal papillary neoplasm of the bile duct (IPNB), intrahepatic cholangiocarcinoma with cystic change, echinococcal cyst, and a simple cyst. Invasive MCNs can only be differentiated from non-invasive MCNs by microscopic evaluation for the presence of ovarian-type stroma. Intraoperative biopsy and frozen section(s) are essential to differentiate MCNs from other cystic liver lesions. The treatment of choice is complete excision and can result in excellent survival with initial correct diagnosis. But its rare presentation and insufficient recognition frequently lead to an incorrect initial or delayed diagnosis or misdiagnosis.

Platelet-rich fibrin for root coverage: A plausible approach in periodontal plastic and esthetic surgery.

Predictable esthetic root coverage has evolved into conventional treatment modalities making cosmetic procedures an integral part of periodontal treatment. The advent of second-generation platelet concentrates, i.e., platelet-rich fibrin (PRF), has broad clinical application in medical as well as dental field with its recent use for recession defects. The simplicity of PRF procurement and its low cost makes it most suitable for use in daily clinical practice. This particular case report foregrounds the benefit of PRF membrane along with coronally repositioned flap for mucogingival surgery on the labial surface of an upper anterior tooth.

Résumé La couverture radiculaire esthétique prévisible a évolué vers des modalités de traitement conventionnelles faisant des procédures cosmétiques une partie intégrante du parodontal traitement. L'avènement des concentrés plaquettaires de deuxième génération, c'est-à-dire la fibrine riche en plaquettes (PRF), a une large application clinique en médecine comme ainsi que le domaine dentaire avec son utilisation récente pour les défauts de récession. La simplicité de l'approvisionnement en PRF et son faible coût le rendent particulièrement adapté utilisation dans la pratique clinique quotidienne. Ce rapport de cas particulier met en avant les avantages de la membrane PRF avec le volet repositionné coronairement pour chirurgie mucogingivale sur la surface labiale d'une dent antérieure supérieure.

Disseminated peritoneal leiomyomatosis: an unusual presentation of intra-abdominal lesion mimicking disseminated malignancy.

Leiomyoma are commonly seen as benign smooth muscle tumors of the uterus. Smooth muscle tumors with unusual growth pattern are rare and include 3 primary neoplasms: intravenous leiomyomatosis (IVL), benign metastasizing leiomyoma (BML) and disseminated peritoneal leiomyomatosis (DPL). DPL is a rare benign disease, often giving the appearance of metastatic ovarian or peritoneal carcinoma. It is a disease that predominately affects women at their reproductive age. The risk of malignant transformation is 2-5%. There are no standard treatment guidelines for the management of the DPL. The unusual presentation of the disease delays the diagnosis or is often misdiagnosed and thus over treated, which may lead to increased morbidity and mortality. Therefore careful consideration and high index of suspicion is required for the proper management of such cases.

A Comparative Study of Uninterrupted Treatment by Radiotherapy versus Standard Gap Correction after Interruptions in Oropharyngeal Cancer.

BACKGROUND: Radiation is an important modality in the treatment of cancer. The longer course of treatment, favors stem cells repopulation, increasing the bulk of stem cells that have to be obliterated. So overall treatment time increases, the chances of local cure by radiotherapy decreases. Primary aim of study is to test the efficacy of radiation treatment after standard correction in unplanned interruption. MATERIAL AND METHOD: 105 patients of head and neck cancer (Oropharynx) with ECOG performance score = 2, with squamous cell carcinoma histopathology and with stage III and IVa were enrolled and 95 patients have completed treatment. Patients were planned for Concurrent chemo-radiotherapy with Cisplatin 40mg/m2 with EBRT (66Gy/33#/2Gy/#) treatment completed in 6.5 weeks. During the treatment the patients were grouped into uninterrupted arm (48) and interrupted arm with standard correction (47). RESULTS: The enrolled patients mean age: 50 years, males 76.8%, stage IVa disease 50.7%, ECOG performance status (0/1: 67.9%). The complete response (CR) in uninterrupted arm was 64.5% and CR in interrupted arm with standard correction was 61.7% at 6 months (X2= 1.883, p value=0.169). While considering alone Stage IV cases, had found that the locally advanced cases of uninterrupted arm have significant better response (X2= 5.90, p value=0.015). The quality of life was slightly poor, but was statistically insignificant in interrupted arm. CONCLUSION: The study concludes that patients with advanced stage (i.e. IVa) have significantly poor treatment outcomes even the standard correction once treatment is interrupted. While the patient treated with gap correction also have similar outcomes in form of disease-free survival and overall survival at 3 years compared to uninterrupted arm.

Toxic Leukoencephalopathy: An unusual Presentation by 5-Fluorouracil Infusion.

BACKGROUND: Toxic leukoencephalopathy predominantly affect white matter of the brain parenchyma. Patient presents either in acute, subacute or chronic phase. The clinical presentation may vary, ranging from mild cognitive impairment to severe neurological dysfunction. It can also mimic psychiatric illness. CASE REPORT: A 50-year-old woman was diagnosed with locally advanced carcinoma buccal mucosa. She was planned for Neoadjuvant chemotherapy consisting of Docetaxel, Cisplatin, 5-FU (TPF). During 3rd day of 3rd cycle of 5-fluorouracil (5FU) infusion, patient developed hypoactive delirium and later became comatose state of drowsiness, with Glasgow Coma Scale (GCS) was 5. There was no previous history for the same. Hence, the infusion was stopped. Patient was evaluated with NCCT head. No abnormality was seen on CT scan. MRI brain was done and it showed diffusion restriction with T2 / FLAIR hyper intensities in bilateral centrum semiovale, white matter of bilateral parietal region and in corpus callosum. Patient received symptomatic care, nutrition by ryles tube during this period and she started to improve after 1st week of onset of symptoms. After 3 weeks, MRI was repeated and there was complete resolution of previous findings. CONCLUSIONS: Development of neurological symptoms during 5FU infusion is a rare entity. Henceforth, occurrence of toxic leukoencephalopathy should be kept in mind. Diffusion weighted imaging play an important role in both acute episode of toxic encephalopathy and in follow up.

Adjuvant Irradiation in Carcinoma Breast Patients: Comparison of 3DCRT and Semi-automated Complex VMAT Hypofractionated Plans.

OBJECTIVE: Adjuvant radiotherapy is required for most post MRM breast cancer patients. Aim of treatment is to target radiation to region of interest while sparing Organs at Risk (OARs). Attempts are being made to decrease dose to OARs without compromising target coverage by evolving radiation techniques. In this study, a comparison of traditional 3DCRT plans is done with semi-automated complex VMAT plans for dose received by OARs namely Contralateral Breast (CLB), Ipsilateral lung (I/LL), and Contralateral Lung (C/LL). MATERIALS AND METHODS: It was planned for 30 post MRM breast cancer patients for chest wall, ipsilateral axilla and supraclavicular lymph node. The PTV dose was 42.5 Gy in 16 fractions, 2.66 Gy/fraction, 5 days a week. For each patient traditional 3DCRT and semi-automated complex VMAT plans (conventional + tangential VMAT plans) were prepared and evaluated by radiation oncologists. RESULTS: Dose evaluation of CLB shows higher Dmax for 3DCRT plans, while, Dmean was lower for the 3DCRT plan. Difference between D2 was not significant. V2.5 was significantly less in 3DCRT, while, difference between V5 and V10 were not significant. For C/LL Dmean, V2.5, V5, and V10 were higher for the VMAT plan. For I/LL Dmean, V5 and V10 were higher, while V20 and V30 were lower for VMAT plans. DISCUSSION AND CONCLUSION: The VMAT technique described here is a useful treatment option available for difficult planning situations. OARs stated above had a mixed result showing VMAT plans to be inferior at lower dose metrics, while, superior at higher dose metrics.

Association between nodal metastasis and histopathological factors in postoperative gingivo-buccal complex squamous cell carcinoma: A Retrospective Study.

OBJECTIVE: To evaluate association between histopathological factors and cervical lymph node metastasis in postoperative gingiva-buccal complex squamous cell carcinoma. METHODS: We retrospectively analyzed 98 postoperative gingiva buccal complex squamous cell carcinoma patients' clinical and histopathological findings. The variables assessed were age, sex, tumour site, tumour size, degree of differentiation (grade), depth of invasion (DOI), lymphovascular invasion (LVI), perineural invasion (PNI) and extracapsular extension (ECE) and their relation with nodal metastasis. RESULT: Out of 98 patients, 76 patients were pathologically node positive (pN+), including 39 of the 53 patients who were classified as cN0 (clinically node negative). The prevalence of occult neck metastasis was 73.5 %. Various parameters like tumour size, LVI, PNI, ECE and Grade showed statistically significant association with lymph node metastasis (p value: 0.029, 0.007, 0.003, 0.001 and 0.001 respectively) on bivariate analysis. Depth of invasion increases incidence of nodal metastasis but was not statistically significant (p value: 0.166). On multivariate logistic regression analysis male gender and presence of PNI were found as independent predicting factors for nodal metastasis (Odds Ratio 7.0826 to 8.65 respectively) while poorly differentiated carcinoma grade appeared non-inferior factor paradoxically (Odds Ratio 0.1033, overall 82.65 % cases were correctly classified by this model and area under ROC curve (AUC) was 0.794 of the model. CONCLUSION: Male gender, poorly differentiated carcinoma and presence of PNI were found as independent predicting factors for nodal metastasis. Male gender and PNI were found risk factors while poorly differentiated carcinoma grade appeared non-inferior factor (protective) paradoxical.

Prostate Carcinoma and Pleural Mesothelioma: An Extremely Rare Co-occurrence.

Pleural mesothelioma and carcinoma prostate as metachronous double malignancy is extremely rare co-occurrence. A 67-year-old male, diagnosed case of carcinoma prostate with bone metastasis, was treated with chemotherapy and hormone therapy. He responded well to chemotherapy and hormone therapy. He remained asymptomatic for two years with serum prostate-specific antigen (PSA) values within normal limits. After two years of diagnosis of carcinoma prostate, he developed left lung pleural sarcomatoid mesothelioma as a second metachronous tumor. Malignant pleural mesothelioma as a metachronous second tumor in a case of carcinoma prostate is rarely reported in the literature. The long-life expectancy, old age, late effects of the treatment, genetic predisposition and lifestyle factors of patients with carcinoma prostate expose them to the possibility of developing second primary tumor.

Modified lip repositioning: A surgical approach to treat the gummy smile.

Gummy smile has been an esthetic concern for many patients. This clinical report describes a successful surgical coverage obtained by modified lip repositioning, thus surgically treating the gummy smile. The technique was performed to limit the retraction of elevator muscles (e.g., zygomaticus minor, orbicularis oris, leviator anguli oris and levator labi oris.) The technique is fulfilled by removing two strips of mucosa from maxillary buccal vestibule on both the sides leaving the frenum untouched and creating a partial thickness flap between mucogingival junction and upper lip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display. This technique is different from the conventional surgical lip repositioning as labial frenum is left untouched over here as it helps in maintain Litton the midline for lip repositioning and reduces the morbidity associated with it.

Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study.

BACKGROUND: The aerosol generated by an ultrasonic scaler contains microorganisms that can penetrate into the body through the respiratory system of dental surgeons and patients. The aim of this pilot study is to evaluate and compare the efficacy of commercially available preprocedural mouthrinses containing 0.2% chlorhexidine gluconate, an herbal mouthwash, and water in reducing the levels of viable bacteria in aerosols. METHODS: This single-center, double-masked, placebo-controlled, randomized, three-group parallel design was conducted over a period of 45 days. Twenty-four patients with chronic periodontitis were divided randomly into three groups (A, B, and C) of eight patients each to receive 0.2% chlorhexidine gluconate, herbal mouthwash, and water, respectively, as a preprocedural rinse. The aerosol produced by the ultrasonic unit was collected at patient's chest area, doctor's chest area, and assistant's chest area on blood agar plates in all three groups. The blood agar plates were incubated at 37°C for 48 hours, and the total number of colony-forming units (CFUs) was counted and statistically analyzed. RESULTS: The results showed that CFUs in groups A and B were significantly reduced compared with group C, P <0.001 (analysis of variance). Also, CFUs in group A were significantly reduced compared with group B, P <0.05 (independent t-test). The numbers of CFUs were highest at the patient's chest area and lowest at the assistant's chest area. CONCLUSION: This study suggests that a routine preprocedural mouthrinse could eliminate the majority of bacterial aerosols generated by the use of an ultrasonic unit, and that 0.2% chlorhexidine gluconate is more effective than herbal mouthwash.

Oral hygiene-awareness and practice among patients attending OPD at Vyas Dental College and Hospital, Jodhpur.

BACKGROUND: According to World Oral Health report 2003, the prevalence of periodontitis is 86% in India. Dental care can sometimes be a forgotten part of a healthy life style. While its importance is often underestimated, the need for regular dental care cannot be overstated. Oral health has been neglected for long in India. The scarce literature on dental health awareness, attitude, oral health-related habits and behavior among the adult population in Rajasthan prompted us to assess the preventive oral health awareness and oral hygiene practices in patients attending outpatient department of Vyas Dental College and Hospital (VDCH), Jodhpur through this study. MATERIALS AND METHODS: A total of 500 patients in the age group 15-50 years were selected using random sampling technique. A self-administered structured questionnaire including 16 multiple choice questions was given to them. The results were analyzed using percentage. RESULTS: The result of this study shows an acute lack of oral hygiene awareness and limited knowledge of oral hygiene practices. In Jodhpur, few people use tooth brush. CONCLUSIONS: Hence, there is an urgent need for comprehensive educational programs to promote good oral health and impart education about correct oral hygiene practices.