NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy.

ABSTRACT: Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Cystic lung disease lymphangioleiomyomatosis (LAM) in a male patient.

Lymphangioleiomyomatosis (LAM) is characterised by the proliferation of abnormal smooth muscle cells (LAM cells) in the lungs, lymph nodes and other organs. We report the case of a man in his 50s who had right-sided pleural effusion. On performing a diagnostic tap, the fluid was milky white in colour. An intercostal chest tube was inserted and after complete drainage of fluid, a high-resolution CT (HRCT) was done. HRCT revealed multiple cysts throughout both of the lungs. On subsequent bronchoscopy-guided transbronchial lung biopsy and histochemical staining, diagnosis of LAM was made. We started the patient on oral sirolimus. On subsequent follow-up, subjective and objective improvements were observed.

Indian Guidelines on Nebulization Therapy.

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Integrating poverty alleviation and environmental protection efforts: A socio-ecological perspective on menstrual health management.

Apt menstrual health management is crucial to the livelihood of low-income, bottom of the pyramid (BOP) women as well as to environmental conservation. However, knowledge is still scant about the factors underpinning women's preferences towards menstrual products, and whether and how the environmental impact of different solutions matter to women's choices. We address this gap by proposing a socio-ecological perspective to understand whether a product's low environmental impact enhances low-income women's uptake of sanitary napkins, thereby supporting poverty alleviation objectives but also efforts geared towards environmental protection. Results from a discrete-choice experiment involving 164 women (n = 1148) in two Indian slums in Delhi and Ahmedabad show that sanitary products' biodegradability is the most important attribute affecting women's preferences towards menstrual hygiene management solutions, which also significantly interacts with women's socio-economic and socio-cultural characteristics. Our findings highlight the potential for business models to find positive synergies between environmental protection and poverty alleviation goals and to situate solutions within the larger socio-ecological context of receiving communities.

Comparison of diagnostic accuracy of digital chest X-ray images between PACS and WhatsApp Messenger in resource poor setting.

PURPOSE: Many underserved remote locations without specialists would benefit from the ability to quickly and easily share images of radiographs with trained radiologists using WhatsApp messenger. However, there is limited evidence on the role of WhatsApp messenger for sharing chest x-ray (CXR) images to aid diagnosis and management. The objective of the study was to determine the diagnostic accuracy and inter-observer agreement of WhatsApp messenger images of digital CXR compared to viewing on Picture Archiving and Communication System (PACS) monitor. METHODS: Two pulmonologists reported 400 WhatsApp messenger images of digital CXR each. After a wash period of two weeks, they reviewed the original CXR images on PACS and again reported their findings. Diagnostic agreement was measured using kappa value, diagnostic accuracy was evaluated by sensitivity and specificity. RESULTS: The diagnostic agreement between WhatsApp and PACS images for both the readers was high in case of normal CXR (0.84), Pneumonia (0.85) and Active Koch's (0.79) and Old Koch's (0.71). The inter-observer agreement between two readers on WhatsApp images was good in cases of normal chest x-ray (0.74), Active Koch's (0.61) and Pneumonia (0.74) and low in COPD (0.31) and Pleural Effusion (0.28) and Carcinoma Lung (0.40). In terms of radiological lesion, inter-observer agreement between two readers on WhatsApp images was good in terms of the zonal involvement, moderate in case of infiltrates, consolidation, nodules, and fibrosis, fair in cavity, effusion (0.28) and poor in hilar lymphadenopathy (0.14). The sensitivity in the diagnosis of nodules, effusion and hilar lymphadenopathy was <50% in both the readers. CONCLUSION: CXR transmission via WhatsApp is able to identify clinical findings similar to viewing the same image on a PACS monitor in cases of Pneumonia and normal subjects. Active and old Koch's has good comparability whereas; diagnostic agreement is poor in COPD, cavity, pleural effusion and hilar lymphadenopathy, requiring more caution during interpretation.

Mobile digital x-ray and portable cartridge based nucleic acid amplification test machines for point-of-care diagnosis of TB in rural India.

BACKGROUND: There is no experience of point-of-care (POC) microbiological confirmation for TB in India in field settings. METHODS: Under the TB-Free Haryana project, a mobile van-mounted digital x-ray and portable GeneXpert system screened all presumptive TB patients with strong clinic-radiological suspicion for TB. RESULTS: Of 1673 x-rays, 215 (13%) had findings suggestive of TB, 109 had strong clinical suspicion and were eligible for POC GeneXpert, in whom a test was performed in 82 (75%) cases; 59 (72%) tested positive and were initiated on treatment within 24 h. CONCLUSIONS: A mobile van equipped with digital x-ray and POC GeneXpert is feasible and has a good success rate with potential for replication.

Implementing upfront mobile digital chest x-ray for tuberculosis diagnosis in India-feasibility and benefits.

BACKGROUND: The Tuberculosis (TB) Control Program in India changed the TB diagnostic algorithm and recommended sputum testing and chest x-ray (CXR) for presumptive TB up front. There is no experience of testing this algorithm in routine field settings. METHODS: In a public-private partnership (PPP), a private hospital provided mobile digital CXR services (mounted on a van) to complement the existing diagnostic services of sputum microscopy and GeneXpert testing. All presumptive TB patients (cough >2 weeks) underwent CXR and sputum microscopy, and GeneXpert testing if eligible (smear-negative CXR suggestive of TB). RESULTS: All 2973 presumptive TB patients underwent CXR and sputum microscopy; 471 (15.8%) had abnormal CXR findings suggestive of TB, 129 (4.3%) were smear positive and 17 were extrapulmonary TB. Of the remaining 325 with smear-negative and CXR suggestive of TB, 147 (45.2%) underwent GeneXpert testing, yielding 32 positives (21.8%). Of the remaining 178 with no GeneXpert test done, 106 (60.0%) had CXR definitely suggesting TB (clinically diagnosed TB). Thus a total of 284 cases of TB (161 microbiologically confirmed, 106 clinically diagnosed, 17 extrapulmonary TB) were identified, giving a potential diagnostic yield of 19.6%. CONCLUSIONS: Systematic screening with mobile digital X-ray service via a PPP model integrated into the national program is feasible and scalable with a high yield.

Pulmonary cryptococcosis: Report of the first confirmed autochthonous case in Nepal.

We report a case of cryptococcal pneumonia in a 53 years old female Nepali patient with uncontrolled diabetes mellitus type 2 who empirically received multiple broad-spectrum antibiotics and standard anti-tubercular treatment as well as glucocorticosteroids for suspected sarcoidosis before the diagnosis was finally established. To our knowledge, this is the first confirmed autochthonous case of cryptococcosis reported from Nepal.

Fifth year of a public-private partnership to improve the case detection of tuberculosis in India: A role model for future action?

BACKGROUND: There is limited access to radiology facilities in most parts of India leading to significant under diagnosis and underreporting of smear negative clinically diagnosed tuberculosis (CDTB). Public Private Partnership (PPP) has a lot to contribute towards addressing this gap through providing access to chest x-ray (CXR) in far-off locations. METHOD: Mobile vans equipped with digital CXR equipment and support staff were provided by a Corporate Hospital working closely with government, with scheduled visits to government peripheral health institutes. Patients received upfront CXR and sputum microscopy along with GeneXpert in accordance with the revised TB diagnostic algorithm prescribed by the national program, Following a successful pilot in 2014 in district Rewari, "TB free Haryana" was launched in November 2015 with a phased roll out in 16 districts by 2018. RESULTS: The pilot initiative in 2014 confirmed practical and clinical feasibility and revealed a high rate (30% of people screened) of CDTB i.e. symptomatic cases with radiologic abnormalities compatible with Pulmonary TB. In the first year (2016), 5 districts were covered and a total of 3340 CXRs were carried out. There was an increase in the case notification rates of new CDTB (smear negative) in 2016 compared to 2015 (p = 0.036); yielding an additional 180 cases and an 11.67% increase in case detection. Scale up to a total of 13 and 16 districts took place successfully in 2017 and 2018 respectively; with 6268 CXRs and 8021 CXRs done in the respective years. CONCLUSION: PPP can involve Corporate Hospitals to improve the existing diagnostic infrastructure and provides access to CXR in a not-for-profit sustainable collaboration, with scale-up to the state level; and potential to replicate this initiative in other states.

Barber's neck manipulation causing bilateral diaphragmatic paralysis and type-2 respiratory failure.

This is a case report of an unusual cause of bilateral diaphragmatic palsy. A 54-year-old gentleman, presented to us with exertional dyspnea and chest heaviness for the past 6 months which had increased in the last 6 days. Dyspnea increased on lying down. He was diagnosed as pneumonia on the basis of X-ray and chest CT scan, received treatment for the same and responded to the therapy. However, breathlessness and hypercapnia persisted. He had unexplained hypercapnia for which extensive investigations were carried out. Neurological and cardiac assessments were essentially normal. On revisit clinical examination, he was found to have paradoxical diaphragmatic movement with respiration. Ultrasound of chest detected no diaphragmatic movement. Detailed history elicited that patient was fond of neck massage and neck cracking wherein his barber would bend his neck with jerk to either side after a haircut.After considering all possible etiologies; we concluded that it was a case of diaphragm palsy induced by barber neck manipulation, leading to Type-2 respiratory failure. The fact that the vital clues to the diagnosis were elicited by detailed history and thorough examination reinforces that history and clinical examination for doctors shall remain a very important tool for clinical diagnosis.

Bullet in tracheobronchial tree without lung contusion removed by fibreoptic bronchoscopy in two parts.

A person presented with multiple gunshot injury. Chest x-ray & CT whole body trauma protocol was done which showed multiples pellets of bullet in abdomen and one bullet in elbow according to entry wound. There was an entry wound without any bullet in left maxillofacial region however there was no exit wound. A bullet was noticed in tracheobronchial tree. There was no pneumothorax any signs of chest trauma or any pneumomediastinum. It is assumed that the bullet first hit the left cheek (maxilla) and lost its momentum. As the patient lost consciousness and had a fall leading to inhalation (aspiration) of bullet in the airway. As per ballistic experts it was basically a jacketed metallic bullet. As bullet moved in airway, the outer metallic core reached the trachea near carina and the soft metallic core slipped more distally to right main bronchus and bronchus intermedius. While inspection the outer metallic capsule was seen in trachea just above carina which was hollow and was gently removed with the help of foreign body forceps. The core was removed with dormia basket without any mucosal tear. The favorable outcome can be attributed as patient had no lung contusion or chest trauma and bullet was inhaled which was not very old. The evolution of bronchoscopy started with rigid one but the fibreoptic bronchoscopy (FOB) has revolutionized the pulmonary interventions. The FOB can be used with minimal traumas under local anesthesia resulting in markedly reduced morbidity and mortality.

Comparison of clinical and cost-effectiveness of two strategies using mobile digital x-ray to detect pulmonary tuberculosis in rural India.

BACKGROUND: Medanta - The Medicity, a multi-super specialty corporate hospital in Gurugram, Haryana launched a "TB-Free Haryana" Campaign; mobile van equipped with a digital CXR machine to screen patients with presumptive Tuberculosis (TB). OBJECTIVES: In this study, we aimed to assess the (1) yield and cost analysis of two strategies using mobile digital x-ray to detect Pulmonary TB in rural Haryana. METHODS: An observational study was conducted on all individuals screened by either of the two case finding strategies using a mobile x-ray unit (MXU) mounted on a mobile van in District Mewat, Haryana during Jan-March 2016. RESULTS: Strategy 1: Out of 121 smear negative cases, x-rays were suggestive of TB in 39(32%), of which 24 were started on TB treatment. Cost of identifying a smear negative TB was US$ 32. Strategy 2: Out of 596 presumptive TB, chest x-rays were suggestive of TB in 108 (18%), of which 67 were started on TB treatment (56 were smear negative TB). Cost of detecting any case of TB was US$ 08 (1 USD = 64 INR). CONCLUSION: The study reports a new initiative within a PPM model to improve the diagnosis of PTB by filling the gap in the current diagnostic infrastructure. We believe there is potential for replication of strategy 2 model in other states, although further evidence is required.

A Prospective Study of Fungal Colonization and Invasive Fungal Disease in Long-Term Mechanically Ventilated Patients in a Respiratory Intensive Care Unit.

BACKGROUND: Long-term mechanical ventilation in an Intensive Care Unit (ICU) exposes the patient to fungal colonization and invasive fungal disease due to the presence of indwelling catheters, administration of broad-spectrum antibiotics, and intravenous corticosteroids. A study is hence required to study the risk factors and incidence of fungal infection in these patients. METHODS: A prospective observational study was carried out in the respiratory ICU of a tertiary care hospital for a period of approximately 1 year in which patients on mechanical ventilation (>7 days) were enrolled. Blood, urine, and endotracheal aspirate (ETA) of these patients were sent for fungal culture on day 1 and day 7 of mechanical ventilation. Fiberoptic bronchoscopy was done on day 7 and bronchoalveolar lavage along with transbronchial lung biopsy (TBLB) were sent for fungal culture. RESULTS: During 7 days of ventilation, there was a statistically significant increase in the proportion of culture-positive ETA and urine samples. Overall, Candida albicans emerged as the most common colonizer. Blood candidemia was seen in 10% of patients on day 7 of mechanical ventilation. Fungal invasion of the lung, as evidenced by fungal culture-positive TBLB specimens, was seen in 17% of patients. Diabetes was found to be a statistically significant risk factor for respiratory and urinary tract colonization as well as invasive fungal disease. CONCLUSION: Long-term mechanical ventilation (>7 days) is strongly associated with fungal colonization of the respiratory tract and urinary tract. Appropriate prophylactic antifungals may be given and infection control practices to be observed to ensure minimum colonization and therefore infection in such settings.

Underlying determinants of health provider choice in urban slums: results from a discrete choice experiment in Ahmedabad, India.

BACKGROUND: Severe underutilization of healthcare facilities and lack of timely, affordable and effective access to healthcare services in resource-constrained, bottom of pyramid (BoP) settings are well-known issues, which foster a negative cycle of poor health outcomes, catastrophic health expenditures and poverty. Understanding BoP patients' healthcare choices is vital to inform policymakers' effective resource allocation and improve population health and livelihood in these areas. This paper examines the factors affecting the choice of health care provider in low-income settings, specifically the urban slums in India. METHOD: A discrete choice experiment was carried out to elicit stated preferences of BoP populations. A total of 100 respondents were sampled using a multi-stage systemic random sampling of urban slums. Attributes were selected based on previous studies in developing countries, findings of a previous exploratory study in the study setting and qualitative interviews. Provider type and cost, distance to the facility, attitude of doctor and staff, appropriateness of care and familiarity with doctor were the attributes included in the study. A random effects logit regression was used to perform the analysis. Interaction effects were included to control for individual characteristics. RESULTS: The relatively most valued attribute is appropriateness of care (ß=3.4213, p = 0.00), followed by familiarity with the doctor (ß=2.8497, p = 0.00) and attitude of the doctor and staff towards the patient (ß=1.8132, p = 0.00). As expected, respondents prefer shorter distance (ß= - 0.0722, p = 0.00) but the relatively low importance of the attribute distance to the facility indicate that respondents are willing to travel longer if any of the other statistically significant attributes are present. Also, significant socioeconomic differences in preferences were observed, especially with regard to the type of provider. CONCLUSION: The analyses did not reveal universal preferences for a provider type, but overall the traditional provider type is not well accepted. It also became evident that respondents valued appropriateness of care above other attributes. Despite the study limitations, the results have broader policy implications in the context of Indian government's attempts to reduce high healthcare out-of-pocket expenditures and provide universal health coverage for its population. The government's attempt to emphasize the focus on traditional providers should be carefully reconsidered.

Role of routine abdominal ultrasonography in intensified tuberculosis case finding algorithms at HIV clinics in high TB burden settings.

BACKGROUND: High proportion of TB in people living with HIV (PLHIV) is undiagnosed. Due to this active TB case finding is recommended for HIV clinics in high TB burden countries. Presently sputum examination and chest radiography are frontline tests recommended for HIV infected TB presumptives. Abdominal TB which occurs frequently in PLHIV may be missed even by existing programmatic intensified case finding protocols. This study evaluated the routine use of ultrasonography (USG) for active case finding of abdominal TB in HIV clinics. METHODS: Retrospective analysis of eight years' data from an HIV Clinic in a TB hospital in India. Patients underwent chest x-ray, sputum examination, USG abdomen and routine blood tests at entry to HIV care. Case forms were scrutinized for diagnosis of TB, USG findings and CD4 cell counts. Abdominal TB was classified as probable or possible TB. Probable TB was based on presence of two major USG (abdomen) findings suggestive of active TB, or one major USG finding with at least two minor USG findings or at least two symptoms, or any USG finding with microbiologically confirmed active TB at another site. Possible TB was based on the presence of one major USG finding, or the presence of two minor USG findings with at least two symptoms. Bacteriological confirmation was not obtained. RESULTS: Eight hundred and eighty-nine people PLHIV underwent a baseline USG abdomen. One hundred and thirteen of 340 cases already diagnosed with TB and 87 of the 91 newly diagnosed with TB at time of HIV clinic registration had abdominal TB. Non-abdominal symptoms like weight loss, fever and cough were seen in 53% and 22% cases had no symptoms at all. Enlarged abdominal lymph nodes with central caseation, ascitis, splenic microabsesses, bowel thickening and hepatosplenomegaly were the USG findings in these cases. CONCLUSIONS: Abdominal TB is a frequent TB site in PLHIV presenting with non-abdominal symptoms. It can be easily detected on basis of features seen on a simple abdominal ultrasound. Abdominal USG should be essential part of intensified TB case finding algorithms for HIV infected people living in high TB burden settings.

Comparative study of clinico-bacterio-radiological profile and treatment outcome of smokers and nonsmokers suffering from pulmonary tuberculosis.

INTRODUCTION: Tuberculosis (TB) is one of the leading causes of death and disease worldwide. Tobacco smoking has been linked as a risk factor for TB. This study was aimed to affirm the strength of association between smoking and pulmonary TB. MATERIALS AND METHODS: Pulmonary TB patients aged between 18 and 65 years were enrolled and followed-up until treatment completion. Two consecutive sputum smears were examined from each patient for the presence of acid-fast bacilli (AFB) using Ziehl-Neelsen technique. Radiological severity of disease was assessed using guidelines of National TB Association of USA. Sputum smears for AFB were graded for positivity as per WHO Revised National TB Control Programme criteria. Response was determined in terms of sputum conversion at the end of intensive phase and final treatment outcomes. RESULTS: Sputum smear grading of 3+ increased from 12.5% to 68.18% and 66.66% as smoking index increased from <100 to 100-299 and >300 (P < 0.05). In nonsmokers, 79.2% patients had minimal disease while only 4.2% had advanced disease as compared to smokers where 52.4% had moderate disease, 26.2% advanced disease, and 21.4% minimal disease (P < 0.01). Smokers had significantly lower treatment success rate (69%) as against nonsmokers and former smokers (93.8% and 90.9%, respectively, P = 0.001) owing to a higher default rate among smokers (28.5%) than nonsmokers (6.3%) and former smokers (9.1%). CONCLUSION: Smokers during initial presentation, as well as at end of the treatment demonstrate more radiological findings, cavitary disease, and worse sputum AFB smear grading. Smokers also have a poorer treatment success rate largely due to high percentage of default rate thus suggesting noncompliance as a main confounder to treatment success. Focus needs to be made to reduce defaulters which are more common among smokers.

Accelerated hypofractionated radiotherapy with concomitant chemotherapy in locally advanced squamous cell carcinoma of lung: evaluation of response, survival, toxicity and quality of life from a Phase II randomized study.

OBJECTIVE: To evaluate the feasibility and efficacy of accelerated hypofractionated radiation with concomitant chemotherapy (AHFx-RT-CT) in locally advanced squamous cell carcinoma (SCC) of the lung. METHODS: 36 patients were enrolled in this study (CTRI/2013/11/004143). Patients in Arm A (n = 18) received neoadjuvant chemotherapy (NACT) (paclitaxel 200 mg m(-2) and carboplatin area under the curve 5) followed by external radiotherapy (60 Gy/30 fractions/6 weeks). Patients in Arm B (n = 18) received NACT as in Arm A followed by AHFx-RT (48 Gy/20 fractions/4 weeks) with concomitant chemotherapy (cisplatin 30 mg m(-2) weekly). Primary end points included comparative evaluation of overall locoregional response rates (ORRs) and progression-free survival (PFS). Secondary end points included toxicity, quality of life (QOL) and overall survival (OS). RESULTS: The median follow-up duration was 15 months. The ORR at first follow-up (72.2% vs 44%, p = 0.06) and at 1 year after treatment completion (61% vs 5.5%, p = 0.04) were superior in Arm B. The median PFS (17 vs 5.36 months; p = 0.053) and OS (24.73 vs 12.33 months; p = 0.007) were also superior in Arm B. Grade ≥3 acute pharyngitis/oesophagitis was less in Arm B (p = 0.05). Improvement of emotional function, cognitive function and chest pain was observed in Arm B. CONCLUSION: The study suggests that AHFx-RT-CT is feasible for locally advanced SCC of the lung with improved response rate, survival, QOL and favourable toxicity. ADVANCES IN KNOWLEDGE: To the best of our knowledge, this is the first study comparing conventionally fractionated radiation with AHFx-RT-CT. Addition of low-dose weekly cisplatin as radiosensitizer may be the potential factor responsible for improved response rate, survival and favourable toxicity in the study arm despite lower biological effective dose.

Efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography as a predictor of response in locally advanced non-small-cell carcinoma of the lung.

OBJECTIVE: The study assessed the role of (18)F-fluorodeoxyglucose ((18)F-FDG) Positron emission tomography (PET)/computed tomography (CT) in evaluating the prognostic value of metabolic response for progression-free survival (PFS) and overall survival (OS) in patients with locally advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Thirty patients with locally advanced NSCLC were enrolled in this prospective study and randomly allocated to one of two treatment arms. Arm A (n=15) received two cycles of neoadjuvant chemotherapy [paclitaxel (200 mg/m(2)) and carboplatin (AUC5)] and external beam radiotherapy (60 Gy/30 fractions/6 weeks). Arm B (n=15) received the same neoadjuvant chemotherapy followed by external beam radiotherapy (48 Gy/20 fractions/4 weeks) with concomitant cisplatin 30 mg/m(2) weekly. Patients underwent (18)F-FDG PET/CT at baseline and after 6 weeks of completion of intended treatment. Pretreatment and post-treatment maximum standardized uptake values (SUVmax) were noted. Patients with a reduction of SUVmax more than 50% were considered to be metabolic responders and those with a reduction 50% or less as nonresponders. Median follow-up was 18.98 months. RESULTS: Twenty-one patients completed the intended treatment. The median pretreatment and post-treatment SUVmax values were 14 and 6.4 for arm A and 15.3 and 3.5 for arm B, respectively. Significant decrease in SUVmax was observed in both arms. Metabolic response in arm A and arm B was 50 and 64%, respectively. The median PFS and OS of the responders were 22.31 and 24.73 months and those for nonresponders were 7.83 and 8.26 months, respectively. No significant difference in OS and PFS was observed between responders and nonresponders in the two arms. CONCLUSION: PET/CT distinguishes responders from nonresponders early after completion of chemoradiation in patients with locally advanced NSCLC, but did not provide any prognostic significance.