Analysis of Set Up Margin Required during Delivery of Conformal Radiotherapy in Head and Neck Malignancy Using On Board Imaging: Experience from Tertiary Care Center

Background : Adequate dose to Clinical Target Volume is needed to control tumour and to deliver adequate dose without missing the target, this Clinical Target Volume must be encompassed by two margins for uncertainties; first, Internal margin uncertainties and second, set up margin uncertainty will form Planning Target Volume. Three mm setup error of couch location resulted in 38% decrease of minimum target radiation dose and 42 % increase of minimal Spinal Cord and Parotid Gland radiation dose. Aims and Objectives : Objectives of this retrospective study are, before implementation of high precession radiotherapy technique for Head and Neck Malignancy, we want determine optimal 3-dimensional Clinical Target Volume to planning target volume margin and to assess our setup accuracy in our institute, NRS Medical College & Hospital, Kolkata. Material and Methods : We analyzed retrospectively set up error from 691 set Cone Beam CT images of 94 patients. According to Standard Guidelines Target Volume delineated and for creation Clinical Target Volume to Planning target volume margin, we have used 5-7 mm margin around Clinical Target Volume. Results : In 99% patients’ setup deviation were within 0.5 cm. The population systematic error (?) in in Super Inferior; mediolateral; and anterior posterior direction were 0.13 cm, 0.12 cm and 0.14 cm respectively. The population random error in Super Inferior; mediolateral; and anterior posterior direction were 0.021 cm, 0.022 cm and 0.173 cm respectively. Using van Herk formula Clinical Target Volume to Planning Target Volume margin in Super Inferior; mediolateral; and anterior posterior direction were 0.34, 0.47 and 0.32 cm respectively. Corresponding values with Stroom formula 0.28, 0.40 and 0.26 cm respectively. Conclusions : In our study Set up margin of 5mm all around the CTV to create PTV is found to be safe and adequete

A study on treatment of locally advanced squamous cell carcinoma of head and neck with radiation along with cisplatin or gefitinib

Background: Cisplatin based Concurrent chemo-radiation (CTRT) is the corner stone for treatment of locally advanced head and neck carcinoma. Epidermal growth factor receptor(EGFR) expression by squamous cell carcinoma which is associated with cancer development and progression,leads to emergence of anti-EGFR agents as a therapeutic option. In this study we compare cisplatin based CTRT against gefitinib based CTRT in terms of disease control and acute toxicity profile. Material and Methods: Stage III and IV squamous cell carcinoma of Head and neck region (excluding nasopharynx) were randomised into two groups. Control group received conventionally fractionated radiotherapy of 66Gy in 33fractions, over six and half weeks with concurrent weekly cisplatin. Study group received same dose of radiation with concurrent daily oral Gefitinib. All patients were followed up weekly during the treatment and then 6-8 weeks after completion of treatment and thereafter 3 monthly. Results: Overall response rate (complete response + partial response) was comparable for both arms (75% vs 76.2%, p value-0.881). Radiation with cisplatin was associated with significantly higher skin (28.6% vs 15%,p value-0.037) and mucosal (23.8% vs 5%,p-value-0.047) toxicities. Gefitinib containing arm showed significantly higher grade 3 diarrhoea (10% vs 0%, p-value-0.01) and skin rash (6% vs 0%, p -value-<0.001).With a median follow-up of 12.5 months Disease free survival (DFS) was not significantly different between the arms(12 vs 13 months). Conclusion: Gefitinib based CTRT is non-inferior to cisplatin based CTRT for the treatment of locally advanced head and neck carcinoma with acceptable toxicity profile.

Castleman Disease: A Rare and Intriguing Malady: A Case Series

Castleman disease (CD), first described by Benjamin Castleman as angiofollicular mediastinal lymph杗ode hyperplasia, is a rare benign lymphoproliferative disorder with varied modes of presentation. Its common presentation within the mediastinum misleads the clinician and merits special attention since it is essentially a diagnosis of exclusion. We are sharing our experience with three patients, within a relatively short period of 2 years. All three presented with a mediastinal mass, however, each of them came with an entirely different clinical scenario and diagnosis. All three were successfully operated and Castleman disease [hyaline杤ascular (HV) type] was diagnosed only after the final histopathology.

A prospective comparative study of concurrent chemoradiation in advanced carcinoma cervix patients with weekly cisplatin vs. weekly cisplatin and paclitaxel

Background: Cisplatin-based concurrent chemoradiation is the standard treatment for carcinoma cervix. However, there is a need to explore alternative chemotherapeutic agents to further improve the treatment outcome. In this study, weekly paclitaxel and cisplatin-based chemoradiation was compared with weekly cisplatin-based chemoradiation in terms of disease control and toxicity profile. Materials and Methods: Sixty-four patients with FIGO stage IB2-IIIB squamous cell carcinoma of the uterine cervix were divided (by simple random sampling) into two groups: control arm patients who received radiotherapy (50 Gy in 25 fractions over 5 weeks) with concurrent weekly cisplatin (40 mg/m 2 ) and study arm patients received same radiation dose with weekly cisplatin (30 mg/m2 ) and paclitaxel (40 mg/m2 ). After that, all patients received brachytherapy 21 Gy/three fractions, one fraction/week. All patients were followed up weekly during treatment, then 4–6 weeks after treatment completion, and thereafter monthly for at least 6 months. Results: The overall treatment response (complete+ partial response) was numerically higher in the cisplatin- containing control arm, but not significant (93% vs. 80%, P-value = 0.406). High-grade early rectal (60% vs. 25%, P-value = 0.014) and acute gastrointestinal toxicity (66% vs. 6%, P-value <0.001) were significantly higher in the cisplatin and paclitaxel-containing arm. Hematological, renal, late rectal, and bladder toxicities were also numerically higher in the study arm, but not statistically significant. Conclusion: There was no significant benefit of weekly paclitaxel and cisplatin as an alternative to weekly cisplatin-based chemoradiation in the treatment of carcinoma cervix.

Correlation of OPG and DEXA: A Case Control Study

Introduction: Osteoporosis is a common disorder affectingolder females. But it remains undetected in many cases. Theaim of the present study is to evaluate the correlation of lowerborder of mandible of OPG and bone mineral density changesas measured by dual energy x ray absorptiometry.Material and methods: 30 female patients were subjected toOPG and DEXA. The visual analysis of OPG was done andcompared with bone mineral density obtained by DEXA.Results: It was found that statistically no significant differencewas observed between OPG and DEXA technique.Conclusion: There is a significant correlation between lowerborder of mandible and bone mineral density. So visualestimation of panoramic radiograph can be used as a screeningtool for evaluation of osteoporosis.

Role of Physiotherapy in the Management of Oral Submucous Fibrosis: A Case Control Study

Introduction: Oral submucous fibrosis is a disorder with nodefinitive treatment. So a treatment that results in symptomaticimprovement in these patients is very important. The aim ofthe present study was to evaluate the use of physiotherapy inthe management of oral submucous fibrosis patients.Material and methods: 30 patients of OSMF were randomlydivided in two groups. Group I – received physiotherapy andwere on regular follow up. Group II- patients did not receivephysiotherapy but were recalled and were under follow up.Results: Significant improvement was observed in patientswith physiotherapy after a period of 4 weeks.Conclusion: Conservative management with physiotherapy iseffective for oral submucous fibrosis.

Incidence of seizures due to degenerative phase of neurocysticercosis: A study in a cohort of primary school children in south India

@#Objective: To study the incidence of seizures due to degenerative phase of neurocysticercosis (NCC) in a cohort of primary school children in south India. Methods: The study cohort included 7,408 (age 5-15 years, boys 44.5% and girls 55.5%) children registered on roles on the date of start of study. The children were followed through first to fifth standard for new-onset of seizures. The data collected included demographic data, date of seizure, any antecedent events, seizure semiology, neurologic findings, 40 minutes EEG findings, and contrast CT brain findings. This analysis is limited to seizures due to degenerative phase of NCC. The average annual incidence rates (AAIR) and 95% confidential intervals (CI) were calculated. Results: During the study period, of the 58 children with new-onset seizure, 19 (32.7%) had seizure due to degenerative phase of NCC [mean age 9.42 years; range7-13 years; 8 boys and 11 girls]. Contrast CT scans in all the 19 children showed solitary cysticercus granuloma (SCG). The common seizure type by mode of onset was focal. The AAIR of seizure disorder was 36.64 (95%CI 22.1-57.2) per 100,000. All the children received antiepileptic drug treatment and four weeks of albendazole and steroids. The seizure disorder resolved with the resolution of the lesion on follow-up CT scan and AEDs were withdrawn. Conclusions: In this highly selective cohort of primary school children from low economic strata, the AAIR of seizure disorder due to degenerative phase of NCC, SCG was high. Seizure disorder due to SCG has an enduring predisposition for seizure recurrence and need AEDs for the period of resolution of lesion and AEDs could safely be withdrawn with the resolution of the lesion.

New-onset unprovoked seizures in a cohort of children in South India: Application of the new ILAE 2014 definition of epilepsy

@#The Indian data comparing the efficacy and safety outcomes of tenecteplase and alteplase in acute ischemic stroke is scarce. We aimed to compare the outcomes of two agents in an Indian population. Methods: TENVALT study was a single centre, retrospective study. Patients aged 18 years or older with acute ischemic stroke were included in this study if they presented within 3 hours of symptom onset and had a deficit with National Institute of Health Stroke Scale (NIHSS) score > 4, had a modified Rankin score (mRS) of 2 or less before the stroke onset and had no evidence of hemorrhage on non-contrast computed tomography of brain. A good functional recovery (mRS score of 0-2) at the end of three months was defined as the primary efficacy outcome. The development of symptomatic intracerebral hemorrhage was considered as the primary safety outcome. Results: A total of 120 patients (alteplase, n=65; tenecteplase, n=55) underwent stroke thrombolysis during this study. The mean age of the presentation in tenecteplase group was 66.6 years and in alteplase group was 62.5 years. Most of the study subjects were males in both the groups (tenecteplase, 78.2%; alteplase, 61.5%). Hypertension was the most common comorbidity in both the groups (tenecteplase, 67.3%; alteplase, 76.9%). Median mRS score at 3 months of follow up was 2 in tenecteplase and 1 in alteplase group; however, the difference between the total number of patients having good functional recovery (mRS 0-2) in the two groups was not statistically significant (tenecteplase 74.5 vs alteplase 87.7%, P=0.09). The total number of patients who had symptomatic intracranial hemorrhage was comparable between the two groups (tenecteplase, 5.5%; alteplase, 6.2%).

The Clinical Relevance of Orthodontic Archwire Properties : A Revuew.

Archwires are the active components of a fixed appliance through which forces are generated and consequently tooth movement is achieved. Recent advances in orthodontic wire alloys have resulted in a varied array of wires that exhibit a wide spectrum of properties. Presently the orthodontist may select from all the available arch wires one that best meets the demands of a particular clinical situation and the efficiency of the operator. The selection of appropriate wire in turn would provide the benefit of optimum and predictable treatment results. The clinician must therefore be conversant with the difference in the mechanical properties and clinical application of this various types of wires

Surgical repair of D-TGA with an aortopulmonary window and ventricular septal defects / Correção cirúrgica da transposição das grandes artérias com janela aortopulmonar e defeitos do septo ventricular

D-Transposition of great arteries with an aortopulmonary window is a rare congenital anomaly. We describe a case of D-Transposition of great arteries with an aortopulmonary window and multiple ventricular septal defects in a 5-month boy who underwent successful surgical repair.

A transposição das grandes artérias com uma janela aortopulmonar é uma anomalia congênita rara. Descrevemos um caso de transposição das grandes artérias com janela aortopulmonar e múltiplos defeitos do septo ventricular em um menino de 5 meses submetido a tratamento cirúrgico com sucesso.

Surgical repair of congenital diaphragmatic eventration in a septugerian lady / Reparo cirúrgico de eventração diafragmática congênita em paciente septuagenária

Congenital diaphragmatic eventration in an elderly is a rare anomaly. We describe a case of congenital diaphragmatic eventration causing respiratory insufficiency in a 72 year lady who underwent successful surgical repair.

A eventração diafragmática congênita em um idoso é uma anomalia rara. Descrevemos um caso de eventração diafragmática congênita que causava insuficiência respiratória em uma idosa de 72 anos, que passou, com sucesso, por uma cirurgia de reparo.

Plasmodium malariae malaria--a case report.

The tropical zone is the endemic home for all malarial parasites. Plasmodium vivax and Plasmodium falciparum are the species that are prevalent commonly in India. Plasmodium malariae is a parasite of both the tropical and subtropical zones, especially West and East Africa, Guiana and parts of India, but its presence in various zones tends to be patchy. In Karnataka state, its prevalence is rare. A case of Plasmodium malariae malaria from St John's Medical College, Bangalore in the background of the rarity of occurrence in this part of the country is presented.

The diagnostic utility of bone marrow trephine biopsies.

The bone marrow examination is invaluable in the diagnosis of certain haematological and non haematological conditions. The diagnosis of haematological disorders is achieved mainly by the examination of peripheral blood and bone marrow aspirate smears. Although bone marrow histology can provide additional information, for many technical reasons, trephines are not so popular and their diagnostic value is overlooked. Our experiences in the role of trephine biopsies in the diagnosis are presented in this article. All the bone marrow biopsies performed at the St. John's Medical College Hospital over the last 12 years (1990-2002) were reviewed The bone marrow biopsies were grouped into 3 categories for analysis. The trephine biopsy is invaluable in cases where the aspirate fails or is a dry tap as in the case of myelofibrosis, focal marrow involvement as in granulomatous lesions, metastatic tumour and lymphomas.

Antiphospholipid antibodies--our experience.

Antiphospholipid antibodies (APA) have aroused multispeciality interests. In our study of 200 cases worked up for APA, we have used a few simple coagulation tests to detect lupus anticoagulant (LA) and ELISA to detect anticardiolipin antibodies. The positivity rate for LA among cases with recurrent pregnancy loss was 4.16% and for aCL 20.8%. The positivity rate for LA in patients with venous thrombosis was 6.2%, in arterial thrombosis was 7.14% and in SLE patients was 58.3%. In conclusion APAs are to be looked for in cases of recurrent pregnancy loss, thrombosis in people < 45 years of age without risk factors and SLE patients to assess the thrombotic risk and to decide on anti coagulant therapy for further management.

Changing trends in malaria--a decade's experience at a referral hospital.

A 10 year study of malaria during 1989-98 recorded an increase in the incidence of malaria from 0.22 in 1989 to 1.3 in 1996 following which it has reached a plateau. The cases were chiefly from Karnataka, Andhra Pradesh and Tamil nadu. The P. falciparum infection and mixed infections (P. falciparum and vivax) were found to be on the rise. Peak of malaria cases were recorded in the months of June-July and in Oct-Nov coinciding with the rains showing a seasonal pattern. The common haematological findings were anemia, thrombocytopenia, pancytopenia and leucopenia. Complications noted in our study were haemolysis, renal failure, hepatopathy and cerebral malaria. The unusual cases were congenital malaria, malaria with sickle cell anemia, AIHA and G-6PD deficiency. Mortality due to cerebral malaria was found to be 13.5%.

Antegrade versus antegrade with retrograde delivery of cardioplegic solution in myocardial revascularisation. A clinical study in patients with triple vessel coronary artery disease.

The effects of antegrade and antegrade with retrograde delivery of cardioplegic solution were evaluated in 60 patients who underwent myocardial revascularisation. All patients had triple vessel coronary artery disease and underwent revascularisation using arterial and vein grafts. Myocardial protection consisted of administration of the St.Thomas' Hospital cardioplegic solution, topical slushed ice and systemic hypothermia (28 degrees C-30 degrees C). The patients were categorised into: group A (n=30), who received antegrade cardioplegia alone, and group B (n=30), who received antegrade and retrograde cardioplegia. With the exception of the total dose of cardioplegic solution ('p'=0.02), there was no significant difference between the two groups. Cardiac function was assessed before and after the patient was weaned from the cardio-pulmonary bypass. There was a significant increase in the right atrial pressure and a significant decrease in the mean arterial pressure from the baseline ('p'<0.05), 10 minutes after cardiopulmonary bypass in group A. All patients in-group B had a spontaneous return to sinus rhythm after release of the aortic cross clamp, whereas 3 patients in group A required defibrillation to restore sinus rhythm. Intra aortic balloon pump support was necessary in 4 patients in group A, as against 1 patient in group B to terminate the cardiopulmonary bypass. The clinical outcome was similar in both groups. We conclude that the use of a combination of retrograde and antegrade cardioplegia facilitates early recovery of left ventricular function after coronary artery bypass grafting.

Haematological changes in HIV infection.

HIV infection is associated with a wide range of hematological abnormalities. The peripheral blood findings and the morphological abnormalities in the bone marrow can simulate myelodysplastic syndrome, myeloproliferative disorders, and T cell lymphoma. We studied the peripheral blood smear and bone marrow findings of 42 patients with HIV infection over a 3-year period with the aim of recognising the morphological findings sufficiently characteristic of HV infection. The salient peripheral blood smear findilngs were anemia, bicytopenia and pancytopenia. The bone marrow revealed trilineage dysplasia, plasma cells and eosinophils, increased megakaryocytes, increased iron and reticulin fibrosis. In two cases the bone marrow revealed granulomata.

Disseminated histoplasmosis in an AIDS patient diagnosed on bone marrow.

A 29 year old male drug addict, who was HIV positive presented with fever and hepatosplenomegaly. Bone marrow examination revealed Histoplasma capsulatum confirmed by PAS & GMS stains. However patient had a rapid downhill course with multiorgan failure and died before specific treatment could be instituted.

Clinicohaematological profile of two cases of inhibitors to factor VIII.

Bleeding is a common manifestation of inherited and acquired disorders of haemostasis. Acquired disorders of haemostasis can be of varied etiology like liver disease, DIC, haemorrhagic disease of newborn and inhibitors to coagulation factors. Inhibitors to coagulation factors are an unusual cause of bleeding which can be superimposed on inherited factor deficiencies or sometimes resembles them. The clinical and haematological profile to two cases of factor VIII inhibitors are being presented here, one of which was a known haemophiliac receiving factor VIII therapy and another was a elderly lady with no other apparent underlying disorder. Hence any case of factor VIII deficiency who becomes refractory to factor VIII replacement therapy or those who are detected to have factor deficiency late in life should be investigated for inhibitors.