Consensus guidelines on management of oral potentially malignant disorders

Oral cancer is usually preceded by oral potentially malignant disorders (OPMDs) and early detection can downstage the disease. The majority of OPMDs are asymptomatic in early stages and can be detected on routine oral examination. Though only a proportion of OPMDs may transform to oral squamous cell carcinoma (OSCC), they may serve as a surrogate clinical lesion to identify individuals at risk of developing OSCC. Currently, there is a scarcity of scientific evidence on specific interventions and management of OPMDs and there is no consensus regarding their management. A consensus meeting with a panel of experts was convened to frame guidelines for clinical practices and recommendations for management strategies for OPMDs. A review of literature from medical databases was conducted to provide the best possible evidence and provide recommendations in management of OPMDs

Cancer awareness & its association with demographic variables & mobile phone usage among the rural population of a district in north India

Background & objectives: Lack of awareness is one of the major reasons for the high morbidity and mortality associated with cancers. The present study was aimed to evaluate the awareness of prevalent cancers among the rural population in a district of north India and its association specifically with mobile phone usage. Methods: Using a stratified random sampling technique, households in three villages of Gautam Buddh Nagar district of India were selected. A house-to-house survey on cancer awareness was conducted among adults in selected households and data were analyzed to check for the association of such an awareness with sociodemographic factors and internet usage. Results: The study included 59 males and 145 females, with majority (115) being in the age group of 18-30 yr. Although most (96.5%) of the participants were aware of cancer, the common risk factors and warning signs of cancer were known to only a few. Specific risk factors for cervical and breast cancers were, however, not known to a majority (79.9% and 72.2%). A significant association between the awareness of general risk factors and warning signs as well as specific aspects including risk factors for breast, cervical and oral cancer, HPV vaccine and the education level of the participants (P<0.05 for all). Knowledge of risk factors, warning signs and cancer prevention modalities was higher among mobile phone users who accessed internet for health information. There was no significant association between age group and cancer risk factor awareness, though females were more aware of the risk factors for breast cancer (P=0.002). Interpretation & conclusions: The findings of this study highlight the existing low level of awareness of cervical and breast cancers among the rural population. The association of cancer awareness with education level and mobile phone-based internet usage suggests the potential utility of internet-based platforms such as m-health programmes for cancer prevention activities

p16 promoter methylation, expression, and its association with estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 subtype of breast carcinoma

Objectives: The purpose of the study is to investigate p16 protein expression and promoter methylation of p16 gene and their association with molecular subtypes based on parameter such as estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Materials and Methods: A total of 114 breast cancer tissue biopsies were collected for methylation-specific polymerase chain reaction (MSP) and immunohistochemical (IHC) analysis. Results: Seven tissue microarrays were constructed. p16 protein expression was studied in 114 cases, of which 35/114 (30.7%) cases showed strong expression and the majority of them had ER-positive tumor (57.6%), and it was statistically significant (P < 0.0074). Similarly, p16 expression was reduced in the majority of PR-negative tumors (83.9%) and the association was statistically significant (P = 0.0026). p16 methylation was studied in 114 cases and was positive in 71.0% cases. Conclusion: High p16 protein expression was associated with ER-positive, PR-negative, and HER2-negative tumors which is associated with poor prognosis. p16 protein expression may be used as a prognostic indicator to predict treatment response to hormonal therapy.

Efficacy of hydrocortisone acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis.

Background & objective: Oral submucous fibrosis is a common premalignant condition caused by chewing arecanut and other irritants in various forms. Its medical treatment is not yet fully standardized, although the optimal doses of its medical treatment is in the form of hydrocortisone acetate combined with hyaluronidase. The problem with the prevailing treatment was injections at weekly interval. In this study we compared the efficacy of hydrocortisone acetate and hyaluronidase at weekly interval versus triamcinolone acetonide and hyaluronidase at 15 days interval. Methods: Patients of OSMF (100) were randomly divided into two groups A and B. Group A patients received combination of hydrocortisone acetate (1.5 ml)/hyaluronidase (1500 IU) at weekly interval submucosally in pterygomandibular raphe, half dose on each side for 22 wk. Group B patients received combination of triamcinolone acetonide (10 mg/ml)/ hyaluronidase (1500 IU) at 15 days interval for 22 wk. Treatment outcome was evaluated on the basis of improvement in symptom score, sign score and histopathological improvement. Student’s ‘t’ test was applied for comparing the results. Results: No statistically significant difference in symptom score, sign score and histopathological improvement was seen between the two groups. Interpretation & conclusion: Treatment regimen of group B was more convenient to the patients because less number of visits required and cheap. No side effects were seen. A follow up study is required to see long term effects.

Multiple intraductal papillomas of breast clinically masquerading as malignancy.

Background: Intraductal papilloma is characterized by proliferation of epithelial and myoepithelial cells overlying fibro-vascular stalks creating an arborescent structure within the lumen of duct. Some times multiple papillomas with florid proliferation of epithelium may be confused with malignancy. A case of multiple intraductal papillomas of breast with ulceration of overlying skin and large lump leading to clinical diagnosis of malignancy is documented here. Case Report: A 45-year-old female presented with ulcerated mass of six months duration in the left breast. On examination, a firm, immobile lump of 8× 10 cm in size involving nipple with excoriation of surrounding skin and serosanguinous discharge from nipple was present. There was no axillary lymphadenopathy. No family history of carcinoma breast was present. Fine needle aspiration smears showed benign cellular changes with apocrine metaplasia. Biopsy from an area adjacent to nipple showed intraductal papilloma. Simple mastectomy showed lobulated dirty white mass with well circumscribed nodules below the nipple and areola. On histology with immunohistochemistry a diagnosis of multiple intraductal papillomas was made. Patient is on regular follow-up and doing well. Conclusion: The case highlights the problem in differentiating marked papillomatosis from a malignant lesion of breast and importance of biopsy with immunohistochemistry in such cases for proper management.

Tobacco control in India: present scenario and challenges ahead.

Tobacco imposes a colossal burden of disease and death leading to catastrophic health, social, economic and environmental effects. Prevalence and practices of tobacco use in India are varied and disparate. Tobacco consumption continues to grow at 2-3% per annum, and by 2020 it is predicted that it will account for 13% of all deaths in the country. India is now demonstrating a steely resolve to contain the menace of tobacco through a comprehensive control strategy that combines several demand and supply reduction measures. India's anti-tobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be inefficient. The 'Cigarettes and Other Tobacco Products Bill, 2003' represented an advance in tobacco control. It included demand reduction measures like outlawing smoking in public places, forbidding sale of tobacco to minors, requiring more prominent health warning labels, and banning advertising at sports and cultural events. India, as a signatory to FCTC, is actively involved in combating the menace of tobacco with renewed fervor. There is a need to devise innovative methods of mobilizing financial and human resources for tobacco control, establish efficient national coordinating mechanisms, integrate tobacco control into health and development programs and periodically evaluate these activities. The Government must also introduce policies to raise taxes, control smuggling, close advertising loopholes, and create adequate provisions for the enforcement of tobacco control laws.

Spectrum of malignancies in Allahabad, North India: a hospital-based study.

OBJECTIVE: To study the spectrum of malignancies in the Allahabad region of North India. This was a hospital-based analysis of malignancies from January 1991 to October 2006. MATERIALS AND METHODS: The basic information in the cancer registry included data on personal identification, demographic characteristics, diagnosis, primary site and morphology of tumours. The basis of diagnosis was histological examination of the biopsy material. RESULTS: Total of 58,031 biopsies were examined, out of which 3,133 (5.4%) were diagnosed as malignancies. Of these, 1,893 (60.4%) patients were males and 1,240 (39.6%) were females, yielding a male: female sex ratio of 1.5:1. The majority of cases (2,772, 88.5%) were above the age of 30, with predominance at 41-50 years of age group (804, 25.6%). Most commonly reported tumours were those of oral cavity (370; 11.8%), oesophagus (267; 8.5%), stomach (239, 7.6%), oropharynx (207, 6.6%), cervix (192, 6.1%), breast (190, 6.0%), larynx (101, 3.2%), skin (81, 3.2%), prostate (77, 2.4%) and the urinary bladder (66, 2.1%). CONCLUSIONS: It is concluded from this retrospective study of tumours reported at this hospital over 16 years, that oral and oropharyngeal malignancies were the commonest malignancies in men, while in females, carcinoma of cervix and breast were the most frequent.

Prevalence of oral pre-malignant and malignant lesions at a tertiary level hospital in Allahabad, India.

OBJECTIVE: In a previous article, we reported the prevalence rates of oral mucosal lesions in this hospital from 1990-2001. This study was planned to study the spectrum of potentially malignant and malignant oral lesions in Allahabad, North India in the subsequent years till 2007 and to assess change in pattern of prevalence, if any. MATERIALS AND METHODS: This is a single institutional retrospective study in and around Allahabad from 1990 to 2007. Data was collected year wise with reference to age, sex, site involved and histopathological findings. RESULTS: 1,151 oral biopsies were reviewed. Of these, 365 biopsies were benign, 344 were potentially malignant and 442 were malignant. The buccal mucosa was the most frequently involved site in benign and premalignant lesions, however in malignant lesions, the tongue was most common site. Oral submucous fibrosis constituted the highest number of patients in premalignant group, while in malignant group, squamous cell carcinoma was most prevalent. CONCLUSION: This study showed that potentially malignant and malignant oral lesions were widespread in the patients visiting the hospital in this region.

HIV seroprevalence in patients with tuberculosis in Allahabad, North India.

250 patients with evidence of pulmonary tuberculosis and 50 nontubercular patients as a control group were subjected to Tuberculin test, Chest X-Ray, sputum microscopy, screening for HIV by ELISA and confirmation by Western blot if ELISA test was found positive. In the study group, 11 tested positive for HIV-1 and 239 tested seronegative, however, in the control group all patients were HIV seronegative. HIV infection was most prevalent in young males in the 21-40 year age group, with a history of tuberculosis, either residing, or working in an urban area away from their family. All our cases were of the HIV-1 serotype.

Pre and post-treatment histopathological changes in atrophic rhinitis.

Atrophic rhinitis is a chronic debilitating nasal mucosal disease of unknown etiology. It is characterized by progressive nasal mucosal atrophy, crusting, fetor and enlargement of the nasal space with paradoxical congestion. The disease induces bilateral nasal obstruction and a persistent foul odour of which the patient and by-standers are painfully aware. Primary atrophic rhinitis has decreased markedly in incidence in the last century. However the prevalence still remains high in developing countries like India. Histopathological features allow this entity to be distinguished from chronic non-specific hypertrophic rhinitis, which may have a cell-mediated immune basis underlying its pathogenesis. Histopathological examination of primary atrophic rhinitis was performed on biopsy material from 30 patients. Mucosal atrophy, squamous metaplasia, and chronic inflammatory cell infiltrate were found to characterize this disease.

Histopathological changes in cases of aluminium phosphide poisoning.

Of a total of 205 poisoning deaths in our hospital in 2003, 83 cases were due to Aluminium phosphide poisoning and were further analyzed. Most vulnerable age group was 21-40 years and M:F ratio was 2:1. On naked eye examination, almost all the vital organs were found to be congested. On microscopic study, the liver showed central venous congestion, degeneration, haemorrhage, sinusoidal dilation, bile stasis, centrilobular necrosis, Kupffer cell hyperplasia, infiltration by mononuclear cells and fatty change. Microscopy of the lungs revealed alveolar thickening, oedema, dilated capillaries, collapsed alveoli and haemorrhage. In the kidney, changes were degeneration, infiltration, tubular dilation and cloudy swelling. Changes in the brain included congestion and coagulative necrosis and in the stomach, congestion and haemorrhage. Easy availability of this cheap and highly toxic substance was responsible for the sudden spurt of poisoning with aluminium phosphide.

Trends of prevalence and pathological spectrum of head and neck cancers in North India.

BACKGROUND: Head and neck neoplasia constitute one of the commonest cancers in India. Use of smokeless tobacco (Pan masala, Zarda etc.) is on the increase in North India, especially in Uttar Pradesh, and is responsible for the large majority of these tumours. AIM: To assess the patients' characteristics, yearly prevalence and histopathological subtypes of the head and neck neoplasia (excluding oral cavity) in Allahabad and surrounding regions. SETTINGS AND DESIGN: A retrospective study of 11 years from 1990 to 2000 was designed. Data was collected year-wise using the tumor registry data. MATERIAL AND METHODS: All biopsies submitted for histopathology to the Pathology department were reviewed and analyzed for demographic data, site and diagnosis. STATISTICAL ANALYSIS: The Kolmogorov-Smirnov Two-Sample Test was utilized to determine whether two distributions are the same. RESULTS: A total of 40559 biopsies were examined in the department, of which, lesions of the head and neck region, excluding the oral cavity, constituted 694 biopsies (409 males and 285 females). One hundred and forty-four malignant lesions were reported, 114 being males and 30 females. A comparison of the age-specific prevalence rates of cancer during the study period showed that the prevalence was highest in patients belonging to the 50-59 years age group and squamous cell carcinoma Grade II was the most prevalent type. On an average, 58 new biopsies per annum were received. CONCLUSIONS: Properly structured site-specific data like this can augment the National Cancer Registry Programme and is an essential indicator for the magnitude and the pattern of the cancer problem in India.

Serial scrape smear cytology of radiation response in normal and malignant cells of oral cavity.

Serial scrape smears were taken from 111 patients receiving radiotherapy for squamous cell carcinoma of the oral cavity. The surface of the tumour and the normal mucosa on the opposite side was scraped before and after delivery of various fractions of radiotherapy and were evaluated by light microscopy. The number of cells exhibiting changes like multinucleation, micronucleation, nuclear budding, binucleation and cytoplasmic granulation were counted. The results were expressed as abnormality per 1000 cells. Each parameter showed a statistically significant increase with radiation dose in both normal and malignant oral cells. In the normal mucosal cells the mean values after 6Gy and 24Gy respectively were 0.83 and 2.91 (p<0.001) for cells with multinucleation, 1.83 and 4.42 (p<0.001) for micronucleation, 2.58 and 5.15 (p<0.001) for nuclear budding, 5.92 and 12.58 (p<0.001) for binucleation, and 3.67 and 7.17 (p<0.001) for cytoplasmic granulation. On the other hand, in malignant cells, the mean values before and after treatment with 24 Gy respectively, were 3.14 and 7.08 (p<0.001) for cells with multinucleation, 1.05 and 5.97 (p<0.001) for micronucleation, 2.54 and 8.82 (p<0.001) for nuclear budding 7.11 and 27.93 (p<0.001) for binucleation and 5.32 and 12.02 (p<0.001) for cytoplasmic granulation. The study showed that there is a dose-related increase in multinucleation, micronucleation, nuclear budding, binucleation and cytoplasmic granulation after various fractions of radiotherapy in both normal and malignant oral cells, however these changes are more marked in the malignant cells.

Use of complementary and alternative medicine by patients with diabetes mellitus.

BACKGROUND: A wide variety of alternative medicines have been traditionally used for the treatment of diabetes in India. We did a cross-sectional study to assess the use of complementary and alternative medicine by patients with diabetes attending our outpatient department. METHODS: Four hundred and ninety-three patients attending the outpatient endocrine clinic for allopathic treatment were included. They were interviewed to assess their knowledge, awareness and methods of practice of non-allopathic forms of therapy. Information on the patients' background characteristics, family history of disease, existing knowledge of their disease and therapy was obtained. RESULTS: The user rate of complementary and alternative medicine was 67.8% and this was not significantly associated with the educational or socioeconomic status of the patients. Desire for early and maximum benefit was the most common reason (86.8%) for using these remedies. The patients felt that acupressure followed by naturopathy were the most beneficial alternative therapies, while homeopathy was felt to have the least benefit in the control of diabetes. CONCLUSION: There was widespread use of complementary and alternative systems of medicine by our patients. It is therefore necessary to obtain objective data to assess the improvement in blood sugar level with, and side-effects of, these methods of treatment.

Radiation-related cytological changes in oral malignant cells.

Carcinoma of the oral cavity constitutes approximately 40% of overall malignant tumours in India, with an incidence of about 56,000 cases per year. Radiation responses in oral cancer cells by cytology have not been extensively studied. 102 patients with squamous cell carcinoma of the oral cavity treated by fractionated radiotherapy were studied. Serial scrape smears were taken from each tumour before and after irradiation. The abnormal nuclear counts per 1000 malignant cells were 1.6 and 14.1(p<0.001) for micronucleation, 0.9 and 5.5 (p<0.001) for nuclear budding, 7.6 and 28.1(p<0.001) for binucleation and 2.4 and 11.7(p<0.001) for multinucleation respectively. The study showed a significant rise in radiation induced cytological responses. In addition, radiation changes observed included abnormal and incomplete divisions of a nucleus, fibroblast like appearance cells, and enlargement of nuclear size as well as cytoplasmic granulation. These changes may have an important role to play in understanding the mechanism of cell killing after radiotherapy.

Fine needle aspiration diagnosis of tuberculous mastitis.

Fine needle aspiration cytology has become the first choice in diagnostic procedures in the management of a variety of breast diseases. The technique can be successfully used to diagnose granuloma in breast aspirates and to demonstrate the presence of acid-fast bacilli. Tuberculosis is rampant in developing countries and patients are prescribed antituberculous therapy on the basis of finding granuloma in breast aspirates without a culture report. In our practice, this principle has been followed with excellent results. In our experience, this technique was reliable and reproducible in diagnosing tuberculous mastitis. We report on the cytomorphological findings of this uncommon but important disorder.

Intramuscular myxoma report of a case diagnosed on fine needle aspiration cytology.

Intramuscular myxoma is a relatively rare soft tissue tumour. Here we present a case which was diagnosed as intramuscular myxoma on cytology and confirmed on histopathology. This is the first such reported case from this country.

Asymptomatic essential thrombocythemia: a case report.

Essential thrombocythemia (ET) is a clonal disorder of unknown etiology involving multipotent hematopoietic progenitor cell and belongs to the spectrum of chronic myeloproliferative disorders (CMPD). It is rarest of the CMPD with no case reported from India. The case being presented was detected incidentally during routine investigations in an adult female who presented with mild abdominal discomfort.