Lung cancer: Presentation and pattern of care in a cancer center in South India.

BACKGROUND: In India lung cancer is the most commonly diagnosed malignancy in males and an increasing trend in the incidence is reported from the National Cancer Registry programme. AIMS: The aim of this study is to find out the recent trends in presentation and management of lung cancer at Regional Cancer Centre, Trivandrum. METHODS: Published reports of hospital based cancer registries (HBCR) and population based cancer registries (PBCR) of Trivandrum were compared with reported statistics from other parts of India and global data. RESULTS: Lung is the leading site of cancer in males (15%) getting treatment at Regional Cancer Centre , Trivandrum in 2013 as per the HBCR. There is an increase in the age adjusted incidence rate of lung cancer among males in the Trivandrum PBCR from 14.6 to 18.5 during 2012 -2014. Among the patients who were treated at the Center majority (55.2%) presented with distant metastases with adenocarcinoma as the most common histological type (28.5%) and only 15.7% had undergone treatment with curative intent. CONCLUSIONS: Lung cancer is the major cancer affecting males in India with a high incidence in Trivandrum and a very low percentage of patients receiving curative treatment which could be due to the high prevalence of tuberculosis and scarce availability of facilities and trained manpower for thoracic oncology.

Saxagliptin co-therapy in C-peptide negative Type 1 diabetes does not improve counter-regulatory responses to hypoglycaemia.

AIMS: To test the hypothesis that dipeptidyl peptidase-4 inhibition in C-peptide negative Type 1 diabetes would reduce glucose variability and exposure to hypoglycaemia and therefore may indirectly enhance counter-regulatory responses to subsequent hypoglycaemia. METHODS: We conducted a 12-week double-blind, randomized, placebo-controlled crossover study. The study was conducted in a tertiary hospital outpatient clinic, with additional studies performed in a clinical research centre. After obtaining informed consent, we recruited 14 subjects with moderately well controlled Type 1 diabetes (HbA1c 64 ± 2 mmol/mol) of long duration (20.5 ± 2.7 years). The subjects received 12 weeks' therapy with oral saxagliptin (5 mg) or placebo. Glucose variability, assessed via continuous glucose monitoring, together with frequency of hypoglycaemia, hypoglycaemia awareness and symptomatic, cognitive and counter-regulatory hormone responses to experimental hypoglycaemia, were assessed. Additional outcome measures included HbA1c level, weight, total daily insulin dose and adverse events. RESULTS: Saxagliptin co-therapy did not reduce glucose variability (low blood glucose index, average daily risk range), hypoglycaemia frequency or awareness and did not improve counter-regulatory hormonal responses during experimental hypoglycaemia (area under the curve for adrenaline 25 775 vs. 24 454, for placebo vs saxagliptin, respectively; P = 0.76). CONCLUSIONS: No additional benefit of dipeptidyl peptidase-4 inhibition co-therapy with saxagliptin in the management of Type 1 diabetes was observed.

Utility of fine needle aspiration cytology in evaluation of lymphadenopathy - An audit from a Cancer Centre in South India.

BACKGROUND: Cytological evaluation and diagnosis of lymphadenopathy plays an important role in distinction between reactive hyperplasia and malignancy.Being a tertiary cancer care centre, lymph node enlargement clinically suspected to be due to malignancy constitute the commonest indication for fine needle aspiration cytology (FNAC) at our centre. The aim of this study was to determine the utility of FNAC in evaluating enlarged lymph nodes and to categorizethe causes of lymphadenopathy diagnosed byFNAC at our centre. MATERIAL AND METHODS: Data was collected from the records of department of Pathology over a period of three months from January to March 2014. The data was analyzed and various parameters studied. RESULTS: There were 2000 aspirates over a period of three months of which 270 (13.5%) were from lymph nodes. Of these, 130 cases (48.2%) have metastatic deposits.We also came across 16 cases (5.9%) of lymphoma, 5 cases (1.9%) of granulomatous lymphadenitis, 2 cases (0.7%) of suppurative lesion and 99 cases (36.7%) of reactive hyperplasia during this period. In 3 cases (1.1%), the lesion turned out to be of salivary gland origin. Aspirates were suboptimal for diagnosis in 15 cases (5.5%). Aspirates were more in males (181) as compared to females (89). The most common site of aspiration was the cervical lymph node(64.5%),followed by supraclavicular=81(30%), inguinal=33(12.22%), axillary=19(7.04%) sub mental=1(0.37%) and others=7(2.59%). Apart from metastatic carcinomas other metastatic malignancies we came across were malignant melanoma, neuroblastoma, germ cell tumor and synovial sarcoma. CONCLUSION: FNAC of lymph nodes helps in rapid diagnosis of lymphadenopathy.Categorizingthe cause of lymph node enlargement as metastatic malignancy,lymphoma, reactive change, inflammatory cause,suppuration etc. can be done by FNAC.In patients with known histologically proven malignancy in whom a subsequent enlargement of lymph node occurs,a cytological diagnosis of metastasis helps in avoiding unwanted surgery for confirming metastasis.In patients without a previous diagnosis of malignancy, FNAC not only confirm metastatic deposit but in most conditions give a clue regarding site of primary. The use of immunocytochemistry and cell block preparations have increased the scope of FNAC.

Role of lymphadenectomy and its impact on survival in endometrial carcinoma - an institutional experience.

UNLABELLED: Pelvic and para aortic lymph nodes are the common sites of metastasis in endometrial carcinoma. The role of lymphadenectomy is widely discussed in literature with varying results. In this study we did a retrospective analysis of endometrial cancer patients to correlate lymphadenectomy with overall and disease free survival. METHODS: A retrospective review of 110 patients with carcinoma endometrium who underwent staging laparotomy at our institute during the period 2006-2010. Patients who underwent node dissections were categorized as group I and the rest as group II. Median lymph node count was 10. Grade of the tumor, nodal status and lymphadenectomy were correlated with overall and disease free survival. CONCLUSION: Lymph node metastasis and grade of tumor are significant predictors of survival. Lymphadenectomy did not show significant survival benefit. It has helped to upstage the disease so that appropriate adjuvant therapy could be planned. A prospective randomized control trial with complete pelvic and para aortic node dissection and uniform adjuvant therapy considering nodal status may help to answer the confusion regarding lymphadenectomy.

Evaluation of stapled closure following laryngectomy for carcinoma larynx in an Indian tertiary cancer centre.

BACKGROUND AND AIM: Stapling devices are used for pharyngeal closure after laryngectomy for the past few decades although it has not gained wide acceptance. This study is aimed at evaluating the role of stapler in pharyngeal closure after laryngectomy. METHODS: Thirty consecutive patients who underwent stapled laryngectomy at our institution from October 2004 to February 2008 were evaluated retrospectively. Linear stapler (Proximate TX 60; Ethicon Inc.) was used for closure of neopharynx. RESULTS: There were 28 males and 2 females with mean age of 54.5 years (54.5 ± 11.2). Nineteen of these patients (63.3%) had salvage laryngectomy and two patients (6.7%) had laryngectomy for a second primary tumor. Twenty-eight patients had total laryngectomy (TL), whereas two had extended TL. Eight patients had salivary leak (26.7%). Of these, 6 (75%) had prior radiation. All salivary leaks except one were managed conservatively. Follow-up ranged from 7 to 54 months (median: 21 months). Seven patients (23.3%) developed recurrence, six at the stoma, of which 5 (83.3%) had initial extension of disease to the subglottis. Four-year disease-free survival was 54.4%. CONCLUSION: Pharyngeal closure by linear stapler is an efficient and safe method of fashioning the neopharynx after laryngectomy with no added risk of occurrence of pharyngocutaneous fistula in primary and salvage laryngectomies.

Factors affecting health related quality of life of rectal cancer patients undergoing surgery.

Maintaining quality of life (QOL) is one of the important aims of cancer treatment. Quality of life of a cancer patient is affected by various factors, which may be disease related, patient related, or treatment related. To study changes in health-related quality of life (HRQOL) brought about by treatment of rectal cancer and factors affecting the changes using Malayalam translation of FACT-C (Functional Assessment of Cancer Therapy-Colorectal) Questionnaire. Also to detect the minimally important clinical changes (MICC) in health-related quality of life of patients with carcinoma rectum, who have undergone surgery. Forty-five patients diagnosed with carcinoma rectum, who have undergone curative surgery, were studied. HRQOL was assessed at baseline 2 weeks after surgery and 3 months after surgery. The changes in scores were correlated with various demographic factors like age, sex, marital status, number of children, number of married children, and education and occupation of the patient and spouse. Also the treatment-related factors like presence of stoma, presence of morbidity, previous treatment, stage of disease, and administration of chemotherapy before and after surgery were correlated. All the subscales of FACT-C tool, except emotional well-being, were significantly reduced 2 weeks after surgery and increased slightly above pre-treatment level 3 months after surgery. The Chronbach α values were 0.88, 0.89 and 0.86 on three occasions, respectively, establishing internal validity of the test. Baseline HRQOL scores were better in males compared to females. Among the various subscales, the drops in SWB, FWB, FACT-G, total Score and TOI were significant (P < .05).There were no significant differences in scores between patients who have undergone open surgery and minimally invasive surgery or patients who had permanent colostomy versus no colostomy. The HRQOL scores after surgery reduced 2 weeks after surgery and improved above pre-surgical levels 3 months after surgery. The approach of surgery (minimally invasive versus open) or presence or absence of permanent colostomy didn't make any significant change in HRQOL. But since the sample size of the study was small, we need further larger studies to arrive at definite conclusions.

Effect of vitamin D supplementation on glycaemic control and insulin resistance: a systematic review and meta-analysis.

AIMS: To systematically review the evidence for the effect of vitamin D supplementation on glycaemia, insulin resistance, progression to diabetes and complications of diabetes. METHODS: Systematic review and meta-analysis. We searched databases including MEDLINE, EMBASE and the Cochrane Library for randomized controlled trials comparing vitamin D or analogues with placebo. We extracted data on fasting glucose, glycaemic control, insulin resistance, insulin/C-peptide levels, micro- and macrovascular outcomes and progression from non-diabetes to diabetes. Studies were assessed independently by two reviewers according to a pre-specified protocol. RESULTS: Fifteen trials were included in the systematic review. Trial reporting was of moderate, variable quality. Combining all studies, no significant improvement was seen in fasting glucose, HbA(1c) or insulin resistance in those treated with vitamin D compared with placebo. For patients with diabetes or impaired glucose tolerance, meta-analysis showed a small effect on fasting glucose (-0.32 mmol/l, 95%CI -0.57 to -0.07) and a small improvement in insulin resistance (standard mean difference -0.25, 95%CI -0.48 to -0.03). No effect was seen on glycated haemoglobin in patients with diabetes and no differences were seen for any outcome in patients with normal fasting glucose. Insufficient data were available to draw conclusions regarding micro- or macrovascular events; two trials failed to show a reduction in new cases of diabetes in patients treated with vitamin D. CONCLUSIONS: There is currently insufficient evidence of beneficial effect to recommend vitamin D supplementation as a means of improving glycaemia or insulin resistance in patients with diabetes, normal fasting glucose or impaired glucose tolerance.

Comparison of esophagectomy with and without thoracotomy in a low-resource tertiary care center in a developing country.

Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60-480 min), which was more than that of open group surgery whose average duration was 261.96 min (60-360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200-500 mL) in minimally invasive group compared with 312.50 (200-500 mL) in open group (P-value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4-24) days in MIS group compared with 12.19 (5-24) days in open group (P-value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P-value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0-19) nodes were removed in MIS group compared with an average of 7.26 (0-12) nodes in open group (P-value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve.

In vitro multiplication ofVanilla planifolia using axillary bud explants.

A clonal propagation method has been developed for efficient multiplication ofVanilla planifolia. Multiple shoots were developed from axillary bud explants using semi-solid Murashige and Skoog (MS) medium supplemented with N6-benzyladenine (BA, 2 mg l-1) and α-naphthaleneacetic acid (NAA, 1 mg l-1). The multiple shoots were transferred to agitated liquid MS medium with BA at 1 mg l-1 and NAA at 0.5 mg l-1 for 2-3 weeks, and subsequently cultured on semi-solid medium. Using this method, an average of 42 shoots were obtained from a single axillary bud explant over a period of 134 days. Use of an intervening liquid medium has been found to enhance multiplication of shoots inV. planifolia.

Clonal multiplication of Gardenia jasminoides Ellis through axillary bud culture.

An efficient clonal multiplication system was developed for in vitro propagation of crocin - producing Gardenia jasminoides Ellis plants. Murashige and Skoog's (MS) medium containing 6-benzylaminopurine (BAP 1 mg l(-1)) and indole-3-butyric acid (IBA 1 mg l(-1)) resulted in multiple shoot initiation at the rate of 21 shoots per explant in 60 d of culture. Transfer of the microshoots into liquid MS medium supplemented with BAP (5 mg l(-1)) with two subcultures of 15 d duration in the same medium resulted in 400 ± 25 shoots per explant. Efficient rooting was achieved in MS medium supplemented with α-naphthaleneacetic acid (5 mg l(-1)). The in vitro raised plants were hardened in a greenhouse and transplanted to the field successfully. The method described will be useful for rapid multiplication of Gardenia for commercial exploitation.