A Randomized Controlled Trial to Evaluate the Role and Efficacy of Oral Glutamine in the Treatment of Chemo-radiotherapy-induced Oral Mucositis and Dysphagia in Patients with Oropharynx and Larynx Carcinoma.

AIM: To determine the role and efficacy of oral glutamine in the treatment of chemo-radiotherapy-induced oral mucositis and dysphagia in patients with carcinoma of the oropharynx and larynx. The primary objective of this study was to compare the incidence and severity of oral mucositis and dysphagia between the glutamine group (oral glutamine, along with concurrent chemo-radiotherapy) and the control group (concurrent chemo-radiotherapy alone, no glutamine). Secondary objectives were to compare the time to onset of oral mucositis and dysphagia, the incidence of treatment breaks (more than three consecutive radiation fractions missed), and significant weight loss (more than 3 kilograms of weight loss from the baseline) between the two groups. METHOD: A total of 60 patients with locally advanced carcinoma of the oropharynx and larynx (Stage III - IV) who were receiving concurrent chemo-radiotherapy were randomised to the glutamine group (study arm, n = 30) and the non-glutamine group (control arm, n = 30). All patients were treated by radiotherapy to a total dose of 70 Gy in 35 fractions, along with concurrent weekly injections of cisplatin (40 mg/m2) chemotherapy. Patients in the study arm received 10 gm of oral glutamine two hours before radiotherapy (five days a week during the seven-week course of radiotherapy). In the control arm, glutamine was not given to patients during the chemo-radiotherapy treatment. All patients were assessed for oral mucositis, dysphagia, weight loss, and compliance/gap in the treatment (greater than three consecutive days of radiation missed) until the completion of chemo-radiotherapy. Grading of oral mucositis and dysphagia was done as per the National Cancer Institute, Common Terminology Criteria for Adverse Events version 4.03. RESULTS: Out of 60 patients, 56 patients (93.33%) completed the full course of chemo-radiotherapy treatment. Twenty-seven patients (96.43%) in the control arm developed Grade III oral mucositis compared to only 12 patients (42.83%) in the glutamine arm (p < 0.001). Twenty-six patients (93%) in the control arm developed Grade III dysphagia compared to only 11 patients (39%) in the glutamine arm (p < 0.001). Glutamine significantly decreased the incidence and severity of mucositis and dysphagia. Glutamine delayed the onset of mucositis and dysphagia. As severe dysphagia was more prevalent in the control arm, feeding by Ryle's tube was required in 17 patients (56.67%) in the control arm versus only in eight patients (26.67%) in the glutamine arm (p = 0.03). Significant weight loss during the treatment was seen in all patients of the control arm (100% patients) compared to only 71% of the patients in the glutamine arm (p = 0.004). In the control arm, 46.67% patients had treatment interruption (gap) compared to 16.67% in the glutamine arm (p = 0.025). Sixteen patients (53%) from the control arm required admission (inpatient care) in the hospital to manage the treatment-toxicity (mucositis and dysphagia) compared to seven patients (23%) from the glutamine arm (p = 0.03). CONCLUSION: Glutamine significantly decreased the incidence and severity of chemo-radiotherapy-induced oral mucositis and dysphagia. It delayed the onset of oral mucositis and dysphagia, improved the compliance to the chemo-radiotherapy treatment, and reduced the requirement for hospitalization for the management of treatment-induced toxicities in patients with locally advanced carcinoma of the oropharynx and larynx.

Plasmacytoma of the Skull-base: A Rare Tumor.

Plasmacytoma of the skull-base is a rare entity. Differential diagnosis includes chordoma, osteosarcoma, carcinoma nasopharynx, meningioma, metastatic carcinoma, lymphoma, and multiple myeloma. Accurate and precise diagnosis is extremely important for plasmacytoma of the skull-base as its treatment and prognosis is different from other skull-base lesions. A 41-year-old man presented with concerns of headache, diplopia, and left eye strabismus. A magnetic resonance image (MRI) of his brain showed a large expansile mass measuring 51 mm involving the clivus and central skull-base. Trans-sphenoidal tumor decompression was done. A biopsy confirmed the plasmacytoma. A positron emission tomography-computed tomography (PET-CT) scan showed a single 2-(18F) fluoro-D-glucose (FDG) avid lesion at the skull-base. The results of all other relevant investigations such as hemoglobin, renal function test, serum calcium, serum protein immunoelectrophoresis, serum quantitative immunoglobulin, bone marrow biopsy, serum lactate dehydrogenase, and beta-2 microglobulin levels were within normal limits. He was treated with radical radiotherapy. He developed complete clinical response after radiotherapy.

Conference report on the Indo Global Summit on Head and Neck Oncology (IGSHNO 2017-BMCON-IV), 24-26 February 2017, Jaipur, India.

'The multidisciplinary approach: expanding treatment horizons for head and neck cancer' was the major theme of the Indo Global Summit on Head and Neck Oncology (IGSHNO 2017-BMCON-IV). The meeting, held in Jaipur (Rajasthan, India) from 24 to 26 February 2017, assembled 600 participants from India and worldwide. It was organised by the Bhagwan Mahaveer Cancer Hospital and Research Centre (BMCHRC), Jaipur. BMCHRC Jaipur is one of the largest superspeciality oncology research and treatment centres in north India. The vision of BMCHRC has been to foster collaboration between oncologists, encouraging dialogue in an open forum that improves the care and outcomes of patients with cancer using the latest advances in cancer treatment. IGSHNO 2017 was part of this aim and vision. The organising team, including Dr Anil Gupta (Organising Secretary), Dr Lalit Mohan Sharma (Organising Secretary), Dr Pawan Singhal (Chairperson, scientific programme), Dr Tej Prakash Soni (Treasurer, Organising Secretary, Radiotherapy workshop), Dr Umesh Bansal and Dr Dinesh Yadav (Joint Organising Secretary), Dr Anjum Khan (Organising Secretary, Palliative care workshop), Dr Gaurav Pal Singh (Organising Secretary, Dental and prosthodontics workshop) and Dr (Maj Gen) SC Pareek (Medical Director, BMCHRC, Jaipur, India) worked hard for the previous 6 months to make this conference a successful academic event. IGSHNO 2017, held over three days, is a chance for oncologists from different parts of India to come together and discuss ongoing research, recent announcements and introduce new developments in head and neck cancer. It consisted of 51 lectures, seven debates, 10 panel discussions, oral paper presentations, e-poster sessions, a quiz for postgraduate students, a live surgery workshop, a prosthodentics workshop for dentists, a radiotherapy contouring workshop for radiation oncologists, a pain and palliative care workshop and a meet the expert session-all focusing on the multidisciplinary treatment of head and neck cancer. Special highlights from IGSHNO 2017 included the radiotherapy contouring workshop, the live surgery workshop by internationally renowned head and neck oncosurgeons, the dental and prosthodontics workshop and the pain and palliative care workshop.

Giant intrathoracic mycotic aneurysm of left subclavian artery.

Fungal infections are serious and important cause of morbidity and mortality in immunocompromised patients. Angioinvasive aspergillosis causing mycotic aneurysm of major blood vessels is very rare and only a few cases are reported in literature. We hereby report one case of acute lymphoblastic leukaemia presenting with this fatal complication.

Retro-peritoneal plasmacytoma: a case report and review of literature.

Solitary Extramedullary Plasmacytoma (EMP) is an uncommon neoplasm. When diagnosed, head and neck region is its most likely location. Rarely, it may occur in the retro-peritoneum. We report a 44 year old man with solitary extramedullary plasmacytoma in the retro peritoneum (RPEMP). The patient did not show response to three cycles of VAD chemotherapy. Thereafter Surgical excision of the mass was performed successfully. This is probably the first case report from Indian subcontinent.