Novel technique of performing transbronchial lung cryobiopsy (TBLC) for diagnosing diffuse parenchymal lung diseases (DPLD) in infants.

Childhood interstitial lung disease (ChILD) diagnosis often requires surgical lung biopsy after the common causes are ruled out. However, surgical lung biopsy has its own set of complications. Hence transbronchial lung cryobiopsy has been used in various studies of adult interstitial lung disease (ILD) with good yield and minimal complications. But this newer mode is rarely used in diagnosing children with suspected ILD. Here, we present the first case of the use of this technique in an infant via a rigid tracheoscope.

Primary Neuroendocrine Carcinoma of the Larynx: A Case Report.

Neuroendocrine tumours can originate from any part of the body. The most common site in the head and neck is the larynx, accounts for less than 0.6%. The neuroendocrine carcinomas (NECs) of the larynx are rare tumours with high incidence of widespread metastases and poor prognosis. Here we report a 50-year-old male with localised primary moderately differentiated NEC of the larynx. He was treated with surgery followed by adjuvant chemotherapy and concurrent chemoradiation. He is free of his disease and is doing well.

Adipose derived mesenchymal stem cell secretome formulation as a biotherapeutic to inhibit growth of drug resistant triple negative breast cancer.

In the present study, a protocol was developed for processing of human adipose derived mesenchymal stem cell secretome formulation of varying concentration. Its molecular composition was evaluated, and its effectiveness in vitro using breast cancer cell lines, and in vivo in a nude mice breast cancer model was studied to determine its role in suppressing triple negative breast cancer in a dose dependent manner. Because the secretome could have value as an add-on therapy along with a current drug, the effectiveness of the secretome both in monotherapy and in combination therapy along with paclitaxel was evaluated. The results showed significant cell kill when exposed to the secretome above 20 mg/ml at which concentration there was no toxicity to normal cells. 70 mg/ml of SF showed 90 ± 10% apoptosis and significant decrease in CD44+/CD24-, MDR1+ and PDL-1+ cancer cells. In vivo, the tumor showed no growth after daily intra tumor injections at 50 mg/ml and 100 mg/ml doses whereas substantial tumor growth occurred after saline intra tumor injection. The study concludes that SF is a potential biotherapeutic for breast cancer and could be used initially as an add-on therapy to other standard of care to provide improved efficacy without other adverse effects.

EGFR analysis on scrapings from cytology smears in lung carcinoma, an effective alternative to testing on trucut biopsies.

BACKGROUND: Lung carcinomas are a leading cause of cancer morbidity and mortality. Many cases present at an advanced stage of disease where definitive treatment by surgical resection is not feasible. Molecular testing using materials derived from minimally invasive procedures aid in targeted therapy with least iatrogenic burden to the patient. METHODS: Cases diagnosed as non-small cell lung carcinoma (NSCLC) on cytology were included in the study. Scrapings from the smears with adequate tumor cell load were submitted for molecular testing. The DNA was extracted and quantified. Mutations in exons 18, 19, 20, and 21 of the EGFR gene were detected using Sanger sequencing. DNA quantity and EGFR mutation status on equal number of consecutive trucut biopsy specimens were also analyzed. RESULTS: Seventy cases of NSCLC tested for EGFR mutation had a median DNA concentration of 40.2 ng/µl and 31% cases showed mutation. Majority of mutations (14/21, 66.66%) were identified in exon 19. Among 70 trucut biopsy samples, DNA concentration was 41.42 ng/µl and 30% cases showed mutation. No significant difference was seen in DNA quantity and EGFR mutation between cytology smears and trucut biopsies. CONCLUSION: EGFR testing on cytology smears provides adequate DNA yield with minimal invasiveness and is equally effective as biopsies. Testing on samples like pleural effusion allows for concomitant diagnosis, staging, and molecular testing in one procedure. Tests done on the smears rather than on cell block or trucut biopsies ensures superior quality DNA from the tumor cells as they are unexposed to cross linking formalin fixative.

Low PDL1 Expression in Tumour Infiltrating Lymphocytes Predicts Local Recurrence in Oral Squamous Cell Carcinoma.

In oral squamous cell carcinoma (OSCC), expression of PDL1 is controversial with expressions showing a positive and negative correlation with survival in previous studies. Additionally, it is unclear whether expression on the tumour or tumour infiltrating lymphocytes (TIL) is a better predictor of survival. We performed this study on a cohort of Indian patients with OSCC to determine impact of PDL1 expression on survival. Retrospective analysis of 64 patients of OSCC treated with curative intent surgery with or without adjuvant therapy was performed. Stored tissue blocks were extracted and quantitative immunohistochemistry was performed for PDL1 expression separately on the tumour and the TIL using commercially available Dako kits. Correlation of clinical and pathological variables with PDL1 expression was performed using chi-square test. Survival analysis was performed using Kaplan-Meier method and Cox proportional hazards ratio. In our cohort, PDL1 expression was low, both in tumour (92% had <1% expression) and TIL (56% had <1% expression). Tumour low PDL1 expression (<1%) was associated with a higher risk of lymphovascular invasion (p = 0.044) and bone invasion (p = 0.01) but did not impact survival. Low TIL PDL1 expression (<1%) was more common in younger patients (<45 years) (p = 0.023) significantly predicting local recurrence (p = 0.02). PDL1 expression in OSCC was low. Low TIL PDL1 was common in younger patients and predicted local recurrence. Further study is required to better understand the relationship between age, tumour microenvironment and local recurrence.

Candidatus Dirofilaria Hongkongensis Infections in Humans During 2005 to 2020, in Kerala, India.

We tried to determine the epidemiology and species of human dirofilariasis observed at two tertiary care hospitals in Kerala. We searched the hospital database to identify cases of dirofilariosis from January 2005 to March 2020. Along with human isolates, one dog Dirofilaria isolate was also subjected to PCR and sequencing of pan filarial primers cytochrome oxidase subunits 1 and 12S rDNA. We documented 78 cases of human dirofilariosis. The orbit, eyelid, and conjunctiva were the most commonly affected sites. Molecular characterization identified one dog and five human isolates as Candidatus Dirofilaria Hongkongensis. A rare case of subconjunctival infestation by B. malayi was also documented. Human dirofilariosis is a public health problem in the state of Kerala in India, and it is mostly caused by Candidatus Dirofilaria Hongkongensis. We propose that all diroifilaria isolates are subjected to sequencing for identification.

Predictive nomograms for oral tongue squamous cell carcinoma applying the American Joint Committee on Cancer/Union Internationale Contre le Cancer 8th edition staging system.

BACKGROUND: Nomograms applying the 8th edition of the TNM staging system aimed at predicting overall (OS), disease-specific (DSS), locoregional recurrence-free (LRRFS) and distant recurrence-free survivals (DRFS) for oral tongue squamous cell carcinoma (OTSCC) are still lacking. METHODS: A training cohort of 438 patients with OTSCC was retrospectively enrolled from a single institution. An external validation set of 287 patients was retrieved from two independent institutions. RESULTS: Internal validation of the multivariable models for OS, DSS, DRFS and LRRFS showed a good calibration and discrimination results with optimism-corrected c-indices of 0.74, 0.75, 0.77 and 0.70, respectively. The external validation confirmed the good performance of OS, DSS and DRFS models (c-index 0.73 and 0.77, and 0.73, respectively) and a fair performance of the LRRFS model (c-index 0.58). CONCLUSIONS: The nomograms herein presented can be implemented as useful tools for prediction of OS, DSS, DRFS and LRRFS in OTSCC.

Diagnostic utility of medical thoracoscopy in T cell lymphoblastic lymphoma presenting with pleural effusion.

Adult lymphoblastic lymphoma (LBL) is an aggressive form of non-Hodgkin lymphoma occurring among predominantly adolescent and young adult men, accounting for 1%-2% of all non-Hodgkin's lymphomas. In contrast to B-LBL, T-cell LBL is much more common, accounting for up to 90% of disease in adults. Mediastinal mass, pleural and/or pericardial effusions are the major characteristics of T-LBL. We report an 27-year-old male with a pleural effusion, mediastinal lymphadenitis, and a normal hemogram. The cytology of the pleural effusion initially was lymphocytic exudative and ADA was high. For definitive diagnosis a medical thoracoscopy was done. The partial pleura showed multiple irregular nodules and thickening in sheets. It was picked and immunophenotypic study revealed the following: CD3, TdTþ, CD7 with Ki 67 index of 70-80%. The patient was finally diagnosed with T-LBL. He was treated with chemotherapy and is on regular follow up with resolution of effusion. The case highlight the point that medical thoracoscopy is a safe and accurate diagnostic procedure for pleural diseases, and partial pleura biopsy yielded the correct diagnosis.

Evaluation of Antigenicity of Components of Tracheal Allotransplant and Effect of Immunosuppressant Regime in a Rodent Model.

Background Tracheal transplantation seems to be the logical step in the process of reconstruction of the trachea following a long-segment resection, which is usually done to treat malignant disease or benign stenosis of the airway caused by a traumatic, congenital, inflammatory, or iatrogenic lesion. Immunosuppression following transplant is essential but not ideal after oncoresection. Methods The tracheal allografts, harvested from Sprague Dawley rats, were implanted in the Wistar strain rat. The harvested tracheal grafts were divided into groups and subgroups, based on the layers of trachea, method of decellularization, and immunosuppression. The antigenicity of different layers of trachea and the effect of various decellularization methods were studied within three time frames, that is, day 3, 9, and 15. Result On structural analysis, the day 3 and day 15 samples showed no meaningful comparison could be made, due to extensive neutrophil infiltration in all three layers. The day 9 tracheal grafts showed loss of epithelium, with no signs of regeneration in most of the allografts. The subepithelial lymphoid infiltration was found to be severe in nonimmunosuppressed allografts. The group in which both inner and outer layers were removed showed moderate-to-severe infiltrate of lymphoid cells in all the allografts, but there was no cartilage loss, irrespective of the method of decellularization. The irradiated specimens retained the cartilage but showed extensive ischemic damage. Conclusion Rat trachea is a good model for tracheal transplant research but not adequately sturdy to sustain mechanical debridement. Irradiation and chemical decellularization eliminates the immune response but causes intense ischemic damage. Out of the three time frames, day 9 seemed to be the best to study the immune response. To substantiate the results obtained in this study, the immunohistochemical study of the allografts is needed to be performed among a larger group of animals.

Digital Breast Tomosynthesis as a Tool in Confirming Negative Surgical Margins in Non-palpable Breast Lesions.

Breast cancer is one of the leading killers among women the world over. Widespread mammographic screening programs have led to almost 20% of breast cancers being detected when they are radiologically visible but clinically impalpable. For the localization of these cancers before surgical excision, the Kopan hook wire is the standard technique, but the extent of margins excised still needs to be determined. In this study, we have evaluated the accuracy of specimen mammogram (SM) with digital breast tomosynthesis (DBT) for margin assessment by comparing it to the excised margins as measured in final histopathology. This is a prospective observational study of patients with radiologically suspicious impalpable breast lesions. The patients underwent ultrasound-guided hook wire placement followed by excision of the lesion, subjected to digital tomosynthesis mammogram, and margins were revised on table when indicated. These findings were correlated with final histopathological margin. Our study included 30 patients and out of the 6 lesions, which showed positive margins on specimen mammography, 4 were histologically confirmed to have tumour at the surgical margin and 2 were confirmed to be tumour free. All DBT-positive margins were re-excised at the time of primary surgery. Individual comparison of the margins revealed a good agreement and high level of correlation between DBT and histopathology margins. None of the cases required a second surgery for margin revision. It can be concluded that specimen mammogram with DBT can be used as a reliable tool for intraoperative surgical margin assessment in non-palpable breast lesions to reduce rate of margin revision as well as reduce the volume of breast excised without compromising the oncological safety of the procedure.

Lymph node staging systems in oral squamous cell carcinoma: A comparative analysis.

OBJECTIVES: The 8th edition of the AJCC has introduced a new nodal staging system for head and neck cancers. Alternate nodal staging systems exist, however they have not been compared to the current AJCC staging system. MATERIALS AND METHODS: A retrospective analysis of 643 patients with oral squamous cell carcinoma (OSCC) treated with surgery ± adjuvant therapy in a single institution between 2004 and 2014 was undertaken. Nodal staging was performed using AJCC 8th edition (AJCC8), number of positive lymph nodes (PN), log odds of positive lymph nodes (LODDS) and lymph node ratio (LNR). Survival analyses for disease free survival (DFS) and overall survival (OS) were performed with the different staging systems and they were compared on the basis of hazard consistency, hazard discrimination, explained variation and likelihood difference. RESULTS: Overall, PN and LNR best predicted OS and DFS in our cohort of patients. AJCC8 had poor discrimination between sub-stages of pN2. CONCLUSION: PN and LNR provided the most accurate prediction of OS and DFS for patients with OSCC.

Predictors of locoregional control in stage I/II oral squamous cell carcinoma classified by AJCC 8th edition.

OBJECTIVES: To study the determinants of locoregional control (LRC) on stage I/II oral squamous cell carcinoma (OSCC) classified by AJCC 8th edition. METHODS: Retrospective analysis from 296 patients of pT1-2N0 oral OSCC treated with surgery (wide local excision and selective neck dissection). Those receiving adjuvant therapy were excluded. Multivariate analysis was performed for impact of adverse pathological features (APFs) on LRC. RESULTS: In stage I, LRC was impacted by perineural invasion (PNI) (HR 7.72, p = 0.010, 95% CI 1.64-36.26) and moderate/poor differentiation (MD/PD) (HR 3.04, p = 0.049, 95% CI 0.99-9.25). In stage II, LRC was impacted by depth of invasion (DOI) (HR 1.59, p = 0.014, 95% CI 1.099-2.32), PNI (HR = 2.86, p = 0.005, 95% CI 1.36-5.98). Combined MD/PD and PNI were associated with worse LRC than either feature individually (HR = 4.12, p < 0.001, 95% CI 2.16-7.85). CONCLUSION: PNI and differentiation accurately predict LRC in AJCC 8th edition classified stage I/II OSCC. PNI was a stronger predictor of locoregional failure than DOI in stage II disease. By incorporating these parameters, we can improve precision in staging of early OSCC and identify potential candidates for treatment escalation to improve outcomes.

Validation of the eighth edition AJCC staging system in early T1 to T2 oral squamous cell carcinoma.

BACKGROUND: To validate the newly proposed American Joint Committee on Cancer (AJCC) eighth edition staging in early T1 and T2 oral cavity cancers and its effect in predicting tumour control. METHODS: Retrospective analysis of treatment outcomes of 441 T1 to T2 oral squamous cell carcinoma (OSCC). Overall survival (OS), disease-specific survival (DSS), and tumour control were calculated and compared between the AJCC 7 and 8 staging systems. RESULTS: The 5-year OS was 78% and 61% for T1 and T2 tumours, respetively (P < 0.001) (AJCC 7) vs 87% and 67% (P < 0.001) (AJCC 8). The 5-year DSS was 78% and 61% for T1 and T2, respectively (P < 0.001) (AJCC 7) vs 89% and 71% (P < 0.001) (AJCC 8). For stages I and II tumours the 5-year OS was 81% and 76%, respectively (P < 0.302) (AJCC 7) vs 87% and 73% (P < 0.017) (AJCC 8). The 5-year DSS was 83% and 82% (P < 0.222) vs 89% and 77% (P < 0.016). With the AJCC eighth edition the 5-year local, regional, and distant control rates for T1 vs T2 tumours were 85% vs 74% (P = 0.003), 95% vs 77% (P = 0.001), and 95% vs 80% (P = 0.014), respectively. CONCLUSION: The AJCC 8th staging system provided for more accurate prediction of OS, DSS, and disease control in early oral cavity cancers.

Brain-Tumor-Regenerating 3D Scaffold-Based Primary Xenograft Models for Glioma Stem Cell Targeted Drug Screening.

Glioma stem cells (GSC) present a critical therapeutic challenge for glioblastoma multiforme (GBM). Drug screening against GSC demands development of novel in vitro and in vivo platforms that can mimic brain microenvironment and support GSC maintenance and tumorigenesis. Here, we report, a 3-dimensionel (3D) biomimetic macro-porous scaffold developed by incorporating hyaluronic acid, porcine brain extra cellular matrix (ECM) and growth factors that facilitates regeneration of GBM from primary GSCs, ex vivo and in vivo. After characterizing with human and rat GBM cell lines and neurospheres, human GSCs expressing Notch1, Sox-2, Nestin, and CD133 biomarkers were isolated from GBM patients, cultured in the 3D scaffold, and implanted subcutaneously in nude mice to develop patient derived xenograft (PDX) models. Aggressive growth pattern of PDX with formation of intratumoral vascularization was monitored by magnetic resonance imaging (MRI). Histopathological and phenotypial features of the original tumors were retained in the PDX models. We used this regenerated GBM platform to screen novel siRNA nanotherapeutics targeting Notch, Sox-2, FAK signaling for its ability to inhibit the tumorigenic potential of GSCs. Current clinical drug, Temozolomide and an anticancer phytochemical, nanocurcumin, were used as controls. The siRNA nanoparticles showed excellent efficacy in inhibiting tumorigenesis by GSCs in vivo. Our study suggests that the brain-ECM mimicking scaffold can regenerate primary gliomas from GSCs in vitro and in vivo, and the same can be used as an effective platform for screening drugs against glioma stem cells.

Metastatic Renal Cell Carcinoma Causing Small Intestinal Polyps with Intussusception: A Report of Two Cases.

Renal cell carcinomas have diverse clinical presentations. Patients may present with metastatic symptoms at the time of diagnosis or years after resection of primary tumour. Small intestine is a rare site for metastatic renal cell carcinoma. Presentation as polypoid metastasis with intussusception is extremely rare. Here, we report two cases with this rare presentation. Case 1 was a 65-year-old male with multiple polypoid metastasis causing intussusception while on palliative chemotherapy for renal cell carcinoma. Case 2 was a 68-year-old female with history of nephrectomy presenting with single polypoid metastasis causing intussusception.

Jejunal Gastric Heterotopia causing Multiple Strictures and Perforation Peritonitis- A Case Report with Review of Literature.

Gastric heterotopias beyond the ligament of Treitz though rare, should be thought of in the differential diagnosis of polypoid lesions presenting with gastrointestinal bleed or obstructive symptoms especially in children and in the young. Here is a 24-year-old male with multifocal jejunal gastric heterotopias causing multiple strictures and perforation peritonitis. Patient presented with acute abdomen pain and an emergency laparotomy was performed revealing jejunum with multiple strictures and perforation, followed by jejunal resection. On gross examination polypoid mucosa was noted at the stricture sites which showed heterotopic gastric mucosa on microscopy. Jejunal gastric heterotopias are extremely rare with less than ten reported cases and those presenting with multiple strictures are even rarer. To our knowledge this is the second case of jejunal gastric heterotopia presenting with multiple strictures.

Nevus comedonicus of the scalp.

A 10-year-old boy presented to us with a localized patch of hair loss on the scalp, first noticed by his mother a few months after birth. The lesion had shown very little increase in size since that time. There was a history of occasional redness and discharge from the lesion, which used to be controlled with topical applications. There was no history of any trauma to the site. There was no family history of any similar lesion or any associated systemic problems. On examination, grouped comedonal lesions were seen over a patch of partial alopecia located on the occipital area of the scalp (Figure 1). There was no evidence of inflammation. Systemic examination was normal. Biopsy specimen from the lesion on the scalp showed foci of wide and deep invaginations of the epidermis filled with keratin. There was no evidence of any significant perifollicular inflammatory infiltrate (Figure 2). A possibility of an atypical nevus comedonicus was considered. The patient was started on topical tretinoin 0.05% and is under follow-up.