Bleomycin-Induced Fibrosis and the Effectiveness of Centella Asiatica as a Treatment.

Introduction: Plant treatment has been used for thousands of years and has been proven to treat acute and chronic diseases. The function of the traditional plant Centella asiatica is as an antimicrobial agent, anticancer, antioxidant, and therapeutic gene in healing wounds and inflammation. Lung fibrosis caused by bleomycin can develop into chronic lung disease, which ends in tissue death if not treated immediately. The purpose of this study is to predict and explain the impact of Centella asiatica extract on model rats exposed to bleomycin in their lungs as a treatment or anti-fibrinolysis. Methods: This research is an analytical study with a randomized in-vivo experimental design divided into 3 groups of 5 male Wistar rats aged 10 weeks. Negative control group (K) with intratracheal induction of bleomycin alone. The positive group was given intratracheal bleomycin 4 mg/kg/BB on days 0 and 21 and added Centella asiatica induction at 400 mg (P1) on days 15 to 49. The other positive group was given intratracheal bleomycin 4 mg/kg/BB on days 0 and 21 and added Centella asiatica induction at 800 mg (P2) on days 15 to 49. Data were collected according to findings of lung histology analysis of rat samples. Results: In the interalveolar septum group, there was a difference in Masson's Trichrome staining results in groups K and P1 with p<0.05 (p=0.036). However, there was no difference in histopathological staining results in groups K and P2 (p>0.05). Conclusion: The induction of bleomycin 4 mg/kg/BB was proven to cause fibrosis in the lungs of rats, and Centella asiatica extract was used as a treatment. Therefore, further research regarding antifibrotic drugs is hoped to reduce fibrotic areas significantly.

Clinical and Bronchoscopy Assessment in Diagnosing the Histopathology Type of Primary Central Lung Tumors.

Background: The location and type of a tumor influence the prognosis of lung cancer. Primary Central Lung Tumors (PCLTs) are correlated with poor prognoses and certain histologic types. This study aimed to present a comprehensive exploration of clinical and bronchoscopic assessments for diagnosing the histopathology types of PCLTs and identified the factors associated with certain histologic types. Methods: This was an observational cross-sectional study of PCLTs, defined as tumors in direct contact with hilar structures or located within the inner two-thirds of the hemithorax. We gathered demographic and clinical data, as well as data on bronchoscopy assessment and histopathology type. Tumor stage, symptoms of superior vena cava syndrome, and enlargement of lymph nodes in the paratracheal and subcarinal regions were also documented. Results: Of the 895 patients, 37.87% had primary lung tumors, with 17.76% classified as PCLTs. Notably, PCLT cases exhibited a higher proportion of stage III (28.9% vs. 18.3%; p = 0.03) and Squamous Cell Carcinoma (SCC) histopathology (37.1% vs. 17.2%; p = 0.00) compared with non-PCLT cases. Bronchoscopic findings in PCLTs revealed a predilection for central airway masses (25.2%) and compressive distal airway stenosis (25.2%). Subgroup analysis of 159 PCLT cases identified 37.10% as SCC. Multivariate analysis underscored that intraluminal masses predict central SCC (odds ratio 2.075, 95% confidence interval 1.07-3.99; p = 0.028). Conclusion: The proportion of stage III, SCC histopathological type, and intraluminal lesions was higher in patients with PCLT than in non-PCLT cases. The presence of intraluminal lesions can predict the histopathological type of SCC in patients with PCLTs.

The Association of Chronic Pulmonary Aspergillosis and Chronic Pulmonary Histoplasmosis with MDR-TB Patients in Indonesia.

In Indonesia, 2.4% of all new tuberculosis patients had multi-drug resistant disease (MDR-TB); an estimated 24,000 incidences. Historical case series of MDR-TB described a high frequency of cavitation and poor prognosis. The diagnosis of chronic pulmonary aspergillosis (CPA) relies on raised levels of Aspergillus IgG antibodies, and detectable Histoplasma IgG antibodies are suspicious for chronic pulmonary histoplasmosis (CPH). We investigated whether MDR-TB patients might have concurrent CPH or CPA. This was a cross-sectional study with 50 MDR-TB patients. ELISA was used to detect Histoplasma IgG antibodies and lateral flow assay was used to detect Aspergillus IgG/IgM antibodies. Several other possible disease determinants were assessed by multivariate analysis. Of the 50 MDR-TB patients, 14 (28%) and 16 (32%) had positive Histoplasma or Aspergillus serology; six patients (12%) had dual antibody reactivity. Radiological abnormalities in positive patients included diffuse or local infiltrates, nodules, consolidation, and apical cavities, consistent with CPH and CPA. Patients with detectable fungal antibodies tended to have worse disease, and 4 of 26 (15.3%) died in the first 5 months of dual infection (p = 0.11 compared with no deaths in those with only MDR-TB). The criteria for the diagnosis of CPH and CPA were fulfilled in those with moderately and far advanced disease (13 of 14 or 93%) and 12 of 16 (75%), respectively. Damp housing was the only determinant associated with Histoplasma antibodies (PR 2.01; 95%CI 0.56-7.19), while pets were associated with the Aspergillus antibody (PR 18.024; 95%CI 1.594-203.744). CPA or CPH are probably frequent in MDR-TB patients in Indonesia and may carry a worse prognosis.

Ewing sarcoma with intra thoracic and multiple extra thoracic metastases in a young adult male: A case report.

INTRODUCTION: Primary chest wall tumors arise from muscle, fat, blood vessels, the nerve sheath, cartilage, or bone of the chest wall. One of the chest wall sarcomas is Ewing Sarcoma (ES), first described in 1921 by James Ewing, which is a highly aggressive bone and soft-tissue cancer. This case report aimed to present an Ewing Sarcoma with intra thoracic and multiple extra thoracic metastases in young adult male patient. PRESENTATION OF CASE: We describe a unique case of metastatic of ewing's sarcoma in a 23-year-old male that showed a mass on the right lower posterior lung with pleural effusion, which was initially thought to be lung tumor that metastasized to the pleura. A thoracic CT scan showed a lobulated soft tissue mass on the right posterolateral thoracic wall, or pleura, with an expansion of soft tissue mass on the rib. Thoracal MRI showed tumor in the posterior right lower thoracic wall area, metastases of the left lateral rib, and right pleural effusion with atelectasis in the right inferior lobe of the lung. The patient also underwent a bone scan, scheduled for palliative radiotherapy and chemotherapy, and consulted to oncology surgeon. DISCUSSION: Ewing sarcoma is a small, round, blue-cell mesenchymal malignancy. ES mainly affects children, adolescents, and young adults, with >1.5 cases per million children. Males are slightly more affected than females (sex ratio of 3:2). The definitive diagnosis requires biopsy proof (achieved by fine needle or core biopsy). The most common regions of metastasis are the lungs, pleural cavity, skeletal system, bone marrow, or combinations of these. CONCLUSION: The 5-year survival rate is approximately 70 % when there is no metastasis; this rate falls to around 30 % when metastasis is present.

Factors influencing histoplasmosis incidence in multidrug-resistant pulmonary tuberculosis patients: A cross-sectional study in Indonesia.

Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum, which in chronic conditions, is generally difficult to distinguish from pulmonary tuberculosis (TB) based on its clinical appearance; therefore, diagnostic errors could occur. Meanwhile, the prevalence of multidrug-resistant pulmonary TB (MDR-TB) in Indonesia remains high. Study determining the incidence of histoplasmosis in MDR-TB is unavailable worldwide. The aim of this study was to determine the risk factors of histoplasmosis incidence in MDR-TB patients in Indonesia. A cross-sectional was conducted at H. Adam Malik General Hospital, Medan, Indonesia and the ELISA platform (semi-quantitative) was used to detect histoplasma antibodies. Factors associated with histoplasmosis incidence among MDR-TB were determined using a Chi-squared test. A total of 50 MDR-TB patients were included this study of which 14 of them (28%) had histoplasmosis. The majority of histoplasmosis occurred in males, in MDR-TB patients with a history of TB treatment and among who had chest x-rays with far-advanced lesions. However, statistical analyses indicated none of those factors (sex, TB treatment history, status of the lung) as well as age group, acid-fast bacillus result, Mycobacterium tuberculosis culture result, having pet, living in damp house, working in the field or plantation, having HIV infection and smoking status were associated with histoplasmosis incidence. This study highlights that the incidence of histoplasmosis is relatively high and therefore further studies are important to be conducted in Indonesia that has a high MDR-TB cases.

The role of oncogenes and tumor suppressor genes in determining survival rates of lung cancer patients in the population of North Sumatra, Indonesia.

Background: Gaining a better understanding of molecular alterations in the pathogenesis of lung cancer reveals a significant change in approach to the management and prognosis of lung cancer. Several oncogenes and tumor suppressor genes have been identified and have different roles related to survival rates in lung cancer patients. This study aims to determine the role of KRAS, EGFR, and TP53 mutations in the survival rate of lung cancer patients in the population of North Sumatra. Methods: This is a retrospective cohort study involving 108 subjects diagnosed with lung cancer from histopathology specimens. DNA extractions were performed using FFPE followed by PCR examinations for assessing the expressions of EGFR, RAS, and TP53 protein. Sequencing analysis was carried out to determine the mutations of EGFR exon 19 and 21, RAS protein exon 2, and TP53 exon 5-6 and 8-9. Data input and analysis were conducted using statistical analysis software for Windows. The survival rate analysis was presented with Kaplan Meier. Results: 52 subjects completed all procedures in this study. Most of the subjects are male (75%), above 60 years old (53.8%), heavy smokers (75%), and suffer from adenocarcinoma type of lung cancer (69.2%). No subjects showed KRAS exon 2 mutations. Overall survival rates increased in patients with EGFR mutations (15 months compared to 8 months; p=0.001) and decreased in patients with TP53 mutations (7 months compared to 9 months; p=0.148). Also, there was increasing Progression-Free Survival in patients with EGFR mutations (6 months compared to 3 months) ( p=0.19) and decreasing PFS in patients with TP53 mutations (3 months compared to 6 months) ( p=0.07). Conclusions: There were no KRAS mutations in this study. EGFR mutations showed a higher survival rate, while TP53 mutations showed a lower survival rate in overall survival and progression-free survival.

A Comparison of Occupational CO Levels, HbCO, and Lung Functions Between Grill and Non-grill Street Vendors.

BACKGROUND: There is a surge increase in grills-fast food outlet in the urban areas that plays an essential role in producing air pollution. Chronic accumulation of carbon monoxide might affect the airway and destroy alveolus as well as correlated with the disturbance of lung function. OBJECTIVE: The purpose of this study is to compare the occupational CO levels, HbCO, and lung functions between grill and non-grill street vendors. METHODS: This was an observational analytic study with a case-control design. The subjects were grill street vendors and non-grill street vendors in Medan city who fulfilled several inclusion criteria. The questionnaire was used to determine some characteristics, while smokerlyzer, and ELISA for expiration CO level and blood CO level, spirometer was used to determining lung function. Logistic regression was performed with p-value < 0.05 considered to be significant using SPSS ver 24.0. RESULTS: A total of 50 subjects enrolled into this study with the majority of subjects in the case group were in red (40%) zone in CO exhaled test with the results in pulmonary function test, predominantly restrictive (56%) and mixed-type (40%) with the mean value of HbCO was 486.16 (ng/mL). Meanwhile, the majority of subjects were green zone with mixed type of lung function disturbance in the control group with 540.15 (ng/mL) as HBCO mean value. Grilled street vendors have a higher level of exhaled CO level (p- value: 0.03) without significant difference in HbCO and lung functions (p-value > 0.05). Age, smoking status, HbCO, and lung function did not significantly affect the CO level (p-value: 0.05). CONCLUSION: There was a significant difference in exhaled CO level between grill-and non-grill street vendors without significant difference in HbCO and lung functions.

A rare primary posterior mediastinal angiolipoma: A case report.

Mediastinal angiolipoma is a rare benign neoplasm composed of mature adipose tissue with an abnormal vessel. Owing to its unspecific symptoms and slow progressions, the diagnosis of this disease is often delayed by clinicians. Here we present a 68-years-old-woman presented with mild chest pain radiates to the back with chronic dry cough. Chest imaging showed right medial posterior intrathoracic mass attached to 3rd-5th vertebrae body without bone destructions. Exploratory thoracotomy with segmentectomy was successfully performed. Histopathology examinations showed adipose tissue surrounded by a blood vessel nest, typical for angiolipoma. The patient showed rapid recovery and was discharged a week after the surgery. After two years of follow-up, the patient showed no sign of tumor recurrence and was clinically stable. This case is the first occurrence of non-infiltrating mediastinal angiolipoma reported in Southeast Asia.

The correlation between hemostatic parameters and mortality rate in patients with non-small cell lung cancer.

The increasing level of hemostatic parameters and tumor markers were associated with cancer progression and poor prognosis, particularly in NSCLC. The objective of this study is to determine whether there was a correlation between hemostatic parameters and mortality rate in patients with NSCLC. This was a prospective analytical study with a pretest-posttest design which included 41 patients with diagnosis of NSCLC. Plasma levels of PT, APTT, TT, D-dimer, and fibrinogen were measured before initiation of chemotherapy and remeasured after 4 cycles or 6 cycles of chemotherapy, based on the clinical condition of patients. Then, patients were followed up for 1 year to evaluate the mortality rate. The majority of subjects were male (85.4%) with adenocarcinoma (75.6%). There was no significant difference in mean between adenocarcinoma and squamous cell carcinoma (P>0.05). Most patients died after one month of follow up (61%). The parameters which could predict high mortality rate in NSCLC were prolonged PT and the increased of D-dimer with RR>1, although they had not significant in statistical analysis (P>0.05). There is no correlation between hemostatic parameters and mortality rate in patients with NSCLC.

The Absence of Mutations in the Exon 2 KRAS Gene in Several Ethnic Groups in North Sumatra May Not the Main Factor for Lung Cancer.

BACKGROUND: Rat Sarcoma (RAS) protein encoded Guanosine Triphosphate (GTP-ase) activity, known as a switch of cell proliferation. The mutation of this protein alters the early stage of carcinogenesis and along with the interaction with other oncogene drivers and environmental factors affect the clinical characteristics and prognosis in cancer patients, particularly lung cancer. OBJECTIVE: This study aims to determine the Kristen Rat Sarcoma (KRAS) mutation in lung cancer patients in North Sumatera and evaluate factors that might contribute in the development of lung cancer in the absence of KRAS mutation. METHODS: This was a retrospective cohort study enrolled 44 subjects age > 18 year with the diagnosis of lung cancer. Histopathology preparation was obtained from surgery, bronchoscopy, and percutaneus needle biopsy then formed as paraffin-block. KRAS mutation was analyzed using Polymerase Chain Reaction (PCR) method with specific primer of exon 2 for evaluating the expression of RAS protein then continued with Sanger Sequencing Method at 12th and 13th codon. RESULTS: The majority of subjects were male, age > 40 years old, bataknese, heavy smoker, with Adenocarcinoma. Almost all the subjects showed the expression of exon 2 of RAS protein in PCR examinations. However, Sequencing analysis using Bioedit Software, BLASTs and Finch T showed GGT GGC as protein base 219-224 which represented 12th and 13th Codon 12 and 13. The results interpreted there was no mutations of exon 2 of KRAS in North Sumatera Population. CONCLUSION: The absence of KRAS mutation in exon 2 in several ethnics in North Sumatera populations was not the main factors of lung cancer.

Tuberculosis of the knee: A pitfalls in clinical settings (A case report and literature review).

INTRODUCTION: Tuberculosis of the knee is a rare form of diseases associated with tuberculosis that is frequently misdiagnosed as malignancy or bacterial infections. Its symptomatology might be identical to other conditions; thus finally turns the clinician misdiagnosed of the patient circumstances. PRESENTATION OF THE CASE: A 31-year-old male patient presented a unilateral knee swelling, reddish, warmth, pain, with a limited range of movement and then diagnosed with tuberculosis of the knee, histopathologically confirmed following surgical removal, including synovectomy without arthroplasty procedure. Furthermore, the patients underwent the administration of an anti-tuberculous drug regiment for a 1-year period. There was clinical improvement attained afterward after the prompt management since the initiation of therapy progressively. DISCUSSION: This case is unique due to the unspecific clinical manifestations of the disease, which contributed to delay diagnosis. Further, either the patients and his parents still had a lack of knowledge according to his condition. Opposite to the recent studies, there was an excellent outcome after simple surgical procedure, including synovectomy without arthroplasty followed by 1 year of anti-tuberculous drug. CONCLUSION: Knee tuberculosis is a rare disease that often misdiagnosed as bacterial infections or malignancy. Mimicking clinical manifestations needs further surgical approach followed by histopathology examination to diagnose this disease. Early recognition and prompt treatment were crucially required to avoid the permanent limitation of movement that could affect the patient's quality of life. In this case, a lack of knowledge of the patient and his family significantly contributes to the delayed diagnosis.

Four-type of Masks and its Effectiveness Based on Reduced Level of Expiratory Carbon-monoxide.

INTRODUCTION: Carbon-monoxide (CO) is a major component of motor-vehicles related air pollution. Motor-vehicles emissions are a major source of air pollution in urban areas and give significant adverse effects on human life. AIM: This study aimed to assess the change of expiratory carbon-monoxide levels after using four-type of masks in people around Universitas Sumatera Utara. METHODS: This was an experimental study with a consecutive sampling technique involved 100 non-smoker subjects. They were divided into four groups based on masks given: fabric, surgical, carbon, and an N95 mask. Expiratory CO was measured by a smokerlyzer device. Data were analyzed using SPSS software with Wilcoxon and Kruskal Wallis Test. RESULTS: There was a significant change of carbon-monoxide mean level after using the mask for 8 hours in a surgical mask, N95 mask, and carbon mask (p-value: 0.002; 0.000; 0.000). After analyzed using Kruskal Wallis Test, there was a significant difference in the change of mean of pre and post wearing mask (ΔCO) among four-type of masks with p-value < 0.001. Post Hoc Analysis showed the significant difference was in the comparison between N95 mask vs Fabric Mask and Carbon Mask vs Fabric Mask (p-value: 0.002; 0.021). CONCLUSION: All three type of masks such as surgical mask, N95 mask, and carbon mask was effective to reduce CO levels from air pollution with the most significant was N95 and carbon mask. Fabric mask has the poorest protection from CO levels.

Clinical Profile of Male Patients with Non-Small Cell Lung Cancer in Adam Malik General Hospital, Medan, Indonesia.

BACKGROUND: Lung cancer is the most frequently found cancer among men around the world and is is the main cause of cancer deaths. The occurrence of lung cancer is particularly associated with smoking habit around men, along with environmental tobacco smoke in the workplace. It is diagnosed in patients with the varied clinical and demographical profile. AIM: We aimed to determine the clinical profile of men with non-small cell lung cancer in Adam Malik Hospital Medan based on age, smoking habits, occupation, clinical symptoms, clinical stage, and type of lung cancer histopathology. MATERIAL AND METHODS: This is a descriptive study using medical record from 2012 to 2015 of all men with non-small cell lung cancer at Adam Malik Hospital Medan, Indonesia. RESULTS: Most men with lung cancer are aged 51-60 years old (43.5%) and work like entrepreneurs. More than 80% of men with lung cancer are heavy smokers. Adenocarcinoma is the most common type of lung cancer, and 2/3 of lung cancer patients are diagnosed at an advanced stage. CONCLUSION: Lung cancer occurs most often in active smokers in the age group above 50 years. The most dominant type of histopathology is adenocarcinoma and is frequently diagnosed in the late stages.

The Characteristic of Secondary Lung Tumours in Medan.

BACKGROUND: Metastatic malignant neoplasms are the most commonly known as secondary lung tumour. Any cancer could have the ability to spread to the lung. The secondary tumour most typically appears on radiologic findings are multiple nodules pleural effusion, etc. AIM: To observe the characteristic of secondary lung tumours patients in Haji Adam Malik General Hospital. MATERIAL AND METHODS: Research design is a cross-sectional with consecutive sampling to 53 patients that are diagnosed with secondary lung tumours. The data was taken from the medical record of secondary lung tumours diagnoses in Haji Adam Malik General Hospital medical record department. RESULTS: From the study, most cases are found in < 40-year-old age group with a percentage of 34%. The highest secondary lung tumour was ovarian carcinoma (13.2%) and multiple nodules (52.8%) from radiology images. Adenocarcinoma is the most found cytology/histopathology type which is around 69.8%. CONCLUSION: Female ages < 40 years are the group with the most cases of secondary lung tumours. Primary tumour from the ovarian is the main cause of secondary lung tumour.

A very rare case of scrofuloderma with multiple cervical lymphadenitis tuberculosis.

Scrofuloderma is a clinical form of secondary cutaneous tuberculosis. It is commonly characterized by bluish-red nodules that cover the lymph nodes, bones or joints, disrupting the affected tissue to be replaced with granulation tissue. We reported a case of 10-year-old boy with ulcers in the cervical and axillary region. The lesion began as papules, which gradually developed into nodules and pustules. Chronic cough was also found, however chest x ray was normal and sputum direct smear for acid fast bacil was negative. Histopathologic finding of tissue biopsy revealed epidermal necrosis in the central part surrounded by granulomatous tissue forming an abscess and histiocyte infiltrates, confirming the diagnosis of scrofuloderma. CT Scan of neck showed multiple enlarged lymph nodes, and FNAB result was suggestive for tuberculous lymphadenitis. Patient was then given anti-tuberculosis therapy. Four months later, the ulcers began to resolve and heal gradually.

Procalcitonin Level in Non-Small Cell Lung Cancer Patients among Indonesian Population.

BACKGROUND: Serum Procalcitonin (PCT) is a biomarker that is frequently used to diagnose an infection. In some cases of thoracic malignancy, procalcitonin level appears to increase. However, the role of procalcitonin to diagnose malignancy is not certain yet, and the causes have not been known. AIM: This study aimed to investigate procalcitonin levels in non-small cell lung cancer patients. METHODS: This was an observational study with a cross-sectional design. All lung cancer patients did not diagnose based on cytology/histopathology results with no evidence nor were signs and symptoms of infection recruited through consecutive sampling. The subtypes of lung cancer include adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, staged III and IV. The procalcitonin levels were analysed from blood using immunofluorescent assay. Data were then analysed with the Chi-Square test by Epi Info™ 7 programs in which p-value < 0.05 was considered statistically significant. RESULTS: A total of 68 lung cancer patients fulfilled the criteria of this study, 55 men (80.9%) and 13 women (19.1%). The highest percentage of cytology/histopathology type found was adenocarcinoma (80.9%), and 60.3% of those were diagnosed in stage IV. An increased procalcitonin level (greater than 0.01 ng/mL) occurred in 80.9% of Non-Small Cell Lung Cancer (NSCLC) patients. It appears that the higher the stage of lung cancer, the lower procalcitonin levels would be, although it was not statistically significant. There was no association between lung cancer subtype with procalcitonin levels. CONCLUSION: An increased level of procalcitonin may be an indication not only for infection but also for Non-Small Cell Lung Cancer.

Analysis of Concordance of Medication-Taking Behaviour in Tuberculosis Patients in Medan, Indonesia.

AIM: This study aimed to analyse tuberculosis (TB) medication-taking behaviour based on the concept of concordance between health workers and TB patients in Medan, Indonesia. METHODS: This study was an analytical study with a cross-sectional design. A total of 100 patients undergoing TB treatment at several public health centres in Medan City participated in the study. RESULTS: The results showed that there was a relationship between the concordance behaviour of the health workers with the attitude and medication-taking behaviour of the patients (p < 0.05). However, there was no relationship found between concordance and knowledge of the patients (p > 0.05). CONCLUSION: The results showed that most of the concordance behaviour, knowledge, attitude, and behaviour in the sample were good.

Genetic Polymorphism of CYP2A6 and Its Relationship with Nicotine Metabolism in Male Bataknese Smokers Suffered from Lung Cancer in Indonesia.

BACKGROUND: Cytochrome P450 2A6 (CYP2A6) is known as an enzyme which is responsible for the metabolism of chemical compounds. AIM: This study aimed to analyse the relationship between CYP2A6 gene polymorphism with nicotine metabolism rates and lung cancer incidence among smokers of Batak ethnic group in Indonesia. METHODS: This study was a case-control study involving 140 research subjects through a purposive sampling technique from three hospitals in Medan, Indonesia. An examination of nicotine metabolism rates was conducted for all subjects using the 3HC/cotinine ratio parameter with LC-MS/MS technique. The examination of the CYP2A6 gene was performed with PCR-RFLP. Data were analysed with Conditional Logistic Regression test using Epi Info 7.0 software. RESULTS: The allele frequencies of CYP2A6*1A, CYP2A6*1B, and CYP2A6*4A found were 44.3%, 48.9%, and 6.8%, respectively. The *1B allele showed the highest metabolism rate. It is found that slow metabolizer individuals were 5.49 times more likely to develop lung cancer (P = 0.01, 95%CI 1.2-24.8). CONCLUSION: Among the Bataknese smokers studied, the CYP2A6*1B allele was found to be the most common allele and showed the highest rate of nicotine metabolism. However, the results show the insignificant relationship among CYP2A6 genetic polymorphism, nicotine metabolism, and lung cancer incidence.

Successful treatment of total paraplegic patient due to tuberculous spondylitis.

A 12-year-old boy presented with progressive disability to walk for four months, which was so severe that he could no longer perform daily activities. No respiratory symptom was found. On physical examination, there was a soft tissue mass in the thoracic vertebrae. Physiological reflexes of both limbs were diminished. Tuberculin skin test was positive with a 12 mm induration. Magnetic resonance imaging (MRI) of the spine showed a kyphotic cervico-thoracal region with predominantly anterior paravertebral mass that was enhanced with contrast, compressing the spinal cord at level Th-3 and Th-4, suggestive of tuberculous spondylitis. He was treated with regular anti-tuberculosis drugs. In the first four months, he began being able to sit, and two months later, he could walk again. After 12 months of treatment without surgery, MRI showed no more compression of the spine and remarkable resolution of paravertebral soft tissue mass. He then resumed his daily life again.

Lung adenocarcinoma presenting with an orbital metastasis.

Orbital metastasis of lung adenocarcinoma is very rare. The incidence is only found to be approximately 7%-12% of lung cancer cases. The lack of knowledge about orbital metastasis results in misdiagnosis between malignant or benign lesion. This was a case of a 39-year-old woman complaining about a protruding left eye and a blind pain in the left eye characterized by hyperemesis eyeball. A CT scan of the orbital showed a soft tissue tumor in the fronto-naso-superomedial area of the left orbital with suspicion of infiltration of the medial rectus muscle, left bulbus oculi, lamina papyracea, and left frontal sinus wall which causes proptosis and soft tissue tumor in the left temporal region with suspicion of infiltration in the left sphenoid wing with an impression of metastasis. A Fine Needle Aspiration Biopsy (FNAB) in the temporal and intra-orbital region showed metastatic adenocarcinoma. Moreover, findings of the chest x-ray and chest CT scan concluded that there was a tumor in the left lung, and a bronchoscopy found adenocarcinoma as the biopsy results.