2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations.

Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.

Comparison of the gross tumor volume in end-expiration/end-inspiration (2 Phase) and summated all phase volume captured in four-dimensional computed tomography in carcinoma lung patients.

PURPOSE: The aim of this study was to compare the delineation and treatment planning of 2 Phase based (end-expiration and end-inspiration) internal gross tumor volume (IGTV) with 10-phase based (four-dimensional [4D]) IGTV. MATERIALS AND METHODS: Patients with lung tumors at different sites were selected for the study. The location of the tumor in Groups A, B, C were at the upper lobe (attached to the chest wall), middle lobe, and lower lobe, respectively. We contoured the GTV on each of the 10 respiratory phases of the 4D computed tomography (4DCT) data set. The combination of these GTVs produced the IGTV "All Phases." GTV was also generated on the extreme respiratory phases. The combination of these two GTVs produced IGTV "2 Phases." Treatment planning was done, and dose to organs at risks (OARs) were compared in both cases. RESULTS: The average volume of IGTV "2 Phases" and IGTV "All Phases" for Group A were nearly same. However, for Group B and Group C, IGTV "2 Phases" were smaller than the IGTV "All Phases." Lung-GTV doses were less in "exp-insp" phases than in "4DCT" for Groups B, C, whereas it was same for "expiration-inspiration" and "4DCT" in Patient A. CONCLUSION: Patients with tumor upper lobe tumor have no difference in tumor coverage and OARs sparing in the 2 Phase and all phases but middle lobe and lower lobe have a greater excursion during respiration and hence greater all phases IGTV.

A Review of Automatic Methods Based on Image Processing Techniques for Tuberculosis Detection from Microscopic Sputum Smear Images.

Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis. It primarily affects the lungs, but it can also affect other parts of the body. TB remains one of the leading causes of death in developing countries, and its recent resurgences in both developed and developing countries warrant global attention. The number of deaths due to TB is very high (as per the WHO report, 1.5 million died in 2013), although most are preventable if diagnosed early and treated. There are many tools for TB detection, but the most widely used one is sputum smear microscopy. It is done manually and is often time consuming; a laboratory technician is expected to spend at least 15 min per slide, limiting the number of slides that can be screened. Many countries, including India, have a dearth of properly trained technicians, and they often fail to detect TB cases due to the stress of a heavy workload. Automatic methods are generally considered as a solution to this problem. Attempts have been made to develop automatic approaches to identify TB bacteria from microscopic sputum smear images. In this paper, we provide a review of automatic methods based on image processing techniques published between 1998 and 2014. The review shows that the accuracy of algorithms for the automatic detection of TB increased significantly over the years and gladly acknowledges that commercial products based on published works also started appearing in the market. This review could be useful to researchers and practitioners working in the field of TB automation, providing a comprehensive and accessible overview of methods of this field of research.

A technique to reduce low dose region for craniospinal irradiation (CSI) with RapidArc and its dosimetric comparison with 3D conformal technique (3DCRT).

We proposed a method to reduce the volume of normal tissues irradiated by low doses in patients receiving CSI with RapidArc (RA) using Avoidance-Sector technique (RA+AS) and to compare its dosimetric implications with RA using full-arc (RA+FA) and 3D conformal technique (3DCRT). Four patients of CSI were retrospectively planned with 3DCRT, RA+FA, and RA+AS. Conformity-Index (CI), Homogeneity-Index (HI), and Paddick Gradient-Index (GI) were calculated. Quantitative evaluation was done using DVH analysis for PTVs and OARs. When compared with 3DCRT, GI, CI, and HI were favorable to RA based techniques. In comparison with 3DCRT the doses to OARs were lower with RA+AS with the difference being statistically significant in most instances. RA+AS significantly decreases the dose to OARs and their volumes receiving low doses in comparison with RA+FA and 3DCRT.

A comparison between four immobilization systems for pelvic radiation therapy using CBCT and paired kilovoltage portals based image-guided radiotherapy.

INTRODUCTION: We commonly use 6- and 4-clamped thermoplastic molds (TMs) for rigid immobilization during pelvic radiotherapy (RT), sometimes a vacuum cushion (VC) is also used as leg support with TM. Our objective was to report the setup margins (SMs) associated with the different systems, to analyze whether any of these systems is superior, and to analyze whether any of them showed better reproducibility in any particular direction. MATERIALS AND METHODS: Retrospective analysis was done by dividing the patients into four groups: 6-clamp with VC (6CVC), 6-clamp without VC (6CNC), 4-clamp with VC (4CVC), and 4-clamp without VC (4CNC). A repeat offline review was done for all patients and errors were tabulated. Statistical methods were then applied. RESULTS: Total 24 patients had 413 image-guided RT (IGRT) sessions, 312 were cone beam computed tomography scan (CBCT) scans and 101 were paired kilovoltage portals (kVp). There was no statistically significant difference between 6CVC and 6CNC. However, while comparing 4CVC and 4CNC, a statistically significant difference was seen in all directions. VC improved precision in vertical and lateral direction mainly, while the 6-clamped TM improved reproducibility in longitudinal direction. CONCLUSIONS: SM was low for all the four immobilization systems studied. There is no added benefit of using a VC with 6-clamped TM for pelvic RT. Use of a VC is recommended with 4-clamped TM to improve overall reproducibility. 6-clamped TM helps keep the errors low.

Image-Guided Radiation Therapy for Muscle-Invasive Carcinoma of the Urinary Bladder with Cone Beam CT Scan: Use of Individualized Internal Target Volumes for a Single Patient.

INTRODUCTION: While planning radiation therapy (RT) for a carcinoma of the urinary bladder (CaUB), the intra-fractional variation of the urinary bladder (UB) volume due to filling-up needs to be accounted for. This internal target volume (ITV) is obtained by adding internal margins (IM) to the contoured bladder. This study was planned to propose a method of acquiring individualized ITVs for each patient and to verify their reproducibility. METHODS: One patient with CaUB underwent simulation with the proposed 'bladder protocol'. After immobilization, a planning CT scan on empty bladder was done. He was then given 300 ml of water to drink and the time (T) was noted. Planning CT scans were performed after 20 min (T+20), 30 min (T+30) and 40 min (T+40). The CT scan at T+20 was co-registered with the T+30 and T+40 scans. The bladder volumes at 20, 30 and 40 min were then contoured as CTV20, CTV30 and CTV40 to obtain an individualized ITV for our patient. For daily treatment, he was instructed to drink water as above, and the time was noted; treatment was started after 20 min. Daily pre- and post-treatment cone beam CT (CBCT) scans were done. The bladder visualized on the pre-treatment CBCT scan was compared with CTV20 and on the post-treatment CBCT scan with CTV30. RESULTS: In total, there were 65 CBCT scans (36 pre- and 29 post-treatment). Individualized ITVs were found to be reproducible in 93.85% of all instances and fell outside in 4 instances. CONCLUSIONS: The proposed bladder protocol can yield a reproducible estimation of the ITV during treatment; this can obviate the need for taking standard IMs.

High strain rate deformation of layered nanocomposites.

Insight into the mechanical behaviour of nanomaterials under the extreme condition of very high deformation rates and to very large strains is needed to provide improved understanding for the development of new protective materials. Applications include protection against bullets for body armour, micrometeorites for satellites, and high-speed particle impact for jet engine turbine blades. Here we use a microscopic ballistic test to report the responses of periodic glassy-rubbery layered block-copolymer nanostructures to impact from hypervelocity micron-sized silica spheres. Entire deformation fields are experimentally visualized at an exceptionally high resolution (below 10 nm) and we discover how the microstructure dissipates the impact energy via layer kinking, layer compression, extreme chain conformational flattening, domain fragmentation and segmental mixing to form a liquid phase. Orientation-dependent experiments show that the dissipation can be enhanced by 30% by proper orientation of the layers.

Genetic screening: The vista of genomic medicine.

The accelerating development of biochemical and DNA-based diagnostic tests for human genetic conditions in the last decade has engendered a revolution in genetic diagnosis. Both genetic testing and genetic screening involve the same testing processes to examine an individual's chromosomes, DNA, or the biochemical product of a gene, typically a protein to confirm or refute a suspected chromosomal, DNA, or gene product change. The identification of genetic disorders, and the potential for developing a therapy, is a powerful force in genetics and medicine.

Revisiting the role of computerized tomographic scan and cystoscopy for detecting bladder invasion in the revised FIGO staging system for carcinoma of the uterine cervix.

INTRODUCTION: Recent revision of the International Federation of Gynecology and Obstetrics (FIGO) staging system for the cervix encourages use of computerized tomography (CT) and magnetic resonance imaging and does not recommend cystoscopy as a mandatory investigation. But the revision has not defined which patients should undergo cystoscopy. Our study aims to revisit the role of CT scan and cystoscopy for detecting bladder invasion so that we can select patients for cystoscopy. METHODS: We reviewed case records of all cervical cancer patients who underwent abdominopelvic CT scan besides standard FIGO staging workup (including cystoscopy) and treatment with radiotherapy or concurrent chemoradiotherapy between years 2003 and 2005. Patients showing bladder invasion on CT scan or cystoscopy were identified and separately analyzed. Considering cystoscopy as the standard reference investigation, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT scan for bladder invasion were calculated. RESULTS: A total of 305 case records were analyzed. Median age of the patients was 50 years (range, 25-85 years). Forty-three (14%) patients had bladder invasion on CT scan, and 17 (5.5%) had cystoscopy-confirmed invasion. No patient showing absence of bladder invasion on CT scan showed cystoscopy-confirmed invasion. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT scan for bladder invasion were 100%, 92%, 40%, 100%, and 92%, respectively. The median overall survival of patients with CT-detected bladder invasion versus cystoscopy-confirmed invasion was 13 months versus 4 months, respectively (P = 0.007). CONCLUSIONS: Our results show that for cervical cancer, cystoscopy is not required in patients without any bladder invasion on CT scan. In the revised FIGO staging system, use of cystoscopy may be limited to patients having suspicious bladder invasion on CT scan. This will benefit both patient population and gynecologic oncologists, especially in developing countries with limited resources.

Rhabdoid variant of lung cancer: clinicopathological details of a case and a review of literature.

Primary rhabdoid tumor of lung is a rare histological and clinical entity. Lung tumors with rhabdoid features have been included as variants of large-cell carcinoma in the 1999 World Health Organization (WHO) classification of lung tumors. A large-cell carcinoma with a rhabdoid phenotype (LCCRP) is unusual, with only 38 cases reported till date. We report the clinical details of one such case that was treated with pneumonectomy and adjuvant chemotherapy. We also present a review of the literature. To identify relevant articles, we searched PubMed, Ovid, and IngentaConnect databases using the key words 'rhabdoid,' 'lung cancer,' and 'primary rhabdoid tumor of lung.'