Combined Metronomic Chemo-immunotherapy (CMCI) in Head and Neck Cancers-An Experience from a Developing Country.

Head and neck squamous cell carcinomas (HNSCC) have proven to be inherently resistant to systemic treatments as a result of histological, molecular, and etiological heterogeneity, with limited responses seen after second-line therapy and beyond. With limited treatment options after progression on systemic chemotherapy in HNSCCs, immunotherapy has a role to play with improved results. In this prospective, observational, non-randomized, open-label study, a total of 12 patients with advanced, relapsed, or metastatic HNSCC received Inj. Nivolumab weight-based dose of 3 mg per kg, intravenously every 2 weeks along with low-dose capecitabine 500 mg twice a day, was prospectively assessed. The patient's clinical, hematological, and staging characteristics were described and the clinical benefit rate (CBR) was calculated. A total of 12 patients received the combined metronomic chemo-immunotherapy (CMCI). The majority of patients were belonging to ECOG-PS 1(66%), with all patients being in stage IV disease. Six, four, and two patients received immunotherapy as the 5th, 3rd, and 4th line of therapy, respectively. Nivolumab and low-dose capecitabine were used in all 12 patients. CBR was seen in 66% (8/12) of patients, one patient died due to hepatitis and hepatic encephalopathy, another patient died due to pneumonia and respiratory complications, two patients had progressive disease, and two patients with stable disease discontinued treatment because of financial constraints and kept on capecitabine alone. The majority tolerated therapy well with no grade 3/4 immune-related adverse events (IRAEs). Two patients required supportive therapy with packed red cell transfusion and albumin infusions. Six-month overall survival (OS) and progression-free survival (PFS) in the study population were 83.3% and 66.6%, respectively. In conclusion, nivolumab along with metronomic chemotherapy with low-dose capecitabine was very well tolerated and exhibited anti-tumor activity with a CBR of 66%, 6-month OS of 83.3%, and 6-month PFS of 66.6%, in extensively pretreated patients with HNSCCs. Additional studies of nivolumab and metronomic chemotherapy and immuno-immuno combination therapy in these diseases are ongoing.

Extraskeletal Ewing's sarcoma of supraglottis: A rare case report.

Ewing's Sarcoma family of tumors is a group of small round tumor cells. Ewing's sarcoma majority occurs in bone, accounts about 10 % of primary bone tumors. Extraskeletal Ewing's sarcoma (ESS) is unusual and commonly seen in trunk, paravertebral, and chest wall region. It is rarely seen in head and neck region, accounting to 2-3 %. In head and neck region, ESS is seen in nasal or oral cavities, sinuses. EES originating in the larynx is very rare. Here, we report a 22 years old female having the complaints of change in voice and noisy breathing who was diagnosed as a case of EES of supraglottis. As the disease progressed during the time of diagnosis, she had to undergo emergency tracheostomy. The disease was inoperable so she received neoadjuvant chemotherapy followed by radiation followed by adjuvant chemotherapy. At present she is symptomatically better. The aim of this report is to put forward the rare site of Ewing's Sarcoma and highlighting the early diagnosis in suspected case with IHC, providing effective multimodality treatment.

Vocal resonance: a narrative review.

Physical examination is an important ritual of bedside medicine that establishes a strong bond between the patient and the physician. It provides practice to acquire important diagnostic skills. A poorly executed bedside examination may result in the wrong diagnosis and adverse outcomes. However, the ritual of obtaining a patient's history and performing a good clinical examination is declining globally. Even the quality of clinical examination skills is declining. One reason may be the short time spent by physicians at the bedside of patients. In addition, due to the substantial technological advancement, physicians often rely more on technology and consider clinical examinations less relevant. In resource-limited settings, thorough history-taking and physical examinations should always be prioritized. An important aspect of respiratory auscultation is the auscultation over the chest wall to detect abnormalities in the transmission of voice-generated sounds, which may provide an important diagnostic clue. Laënnec originally described in detail three types of voice-generated sounds and named them bronchophonism, pectoriloquism, and egophonism. Subsequently, they are known as bronchophony, whispering pectoriloquy, and egophony. A recent variant of egophony is "E-to-A" changes. We searched PubMed, EMBASE, and the CINAHL from inception to December 2023. We used the following search terms: vocal resonance, bronchophony, egophony, whispering pectoriloquy, auscultation, etc. All types of studies were chosen. This review will narrate the physics of sound waves, the types of vocal resonance, the mechanisms of vocal resonance, the methods to elicit them, and the accuracy of vocal resonance.

Treating low- and intermediate-risk acute promyelocytic leukemia with and without chemotherapy: A comparison in a tertiary care center.

Background: Acute promyelocytic leukemia (APL) comprises approximately 10% of acute myeloid leukemia (AML) cases. Material and Methods: Both options of treatment (ATRA-ATO and ATRA-chemotherapy) were discussed with patients with low- and intermediate-risk APL, pros and cons explained in details, and treatment regimen selected after getting informed written consent. Results: Total 71 patients were included in the study; among these patients, 3 were negative for both FISH for t (15,17) and RT-PCR for promyelocytic leukemia retinoic acid receptor alpha, and 36 patients with APL had white blood cell count at diagnosis >10 × 109/l. Total 30 patients with newly diagnosed as low- and intermediate-risk-APL fulfilled all inclusion criteria, treated and followed for a minimum period of 2 years up to June, 2016. Fifteen patients liked to be treated with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), while rest of the 15 patients preferred treatment with ATRA and chemotherapy. Conclusion: Combination of ATRA and ATO is equally effective, less toxic, and more feasible in comparison to ATRA and chemotherapy for patients with low- and intermediate-risk APL and is a viable option for this subset of patients, especially in countries with limited resources.

Severe persistent marrow aplasia in chronic myeloid leukemia (CML): An unusual complication of imatinib.

Background: Imatinib has changed the treatment of chronic myeloid leukemia (CML) drastically since 15 years. It is usually well tolerated, but severe persistent marrow aplasia is an unusual complication of imatinib while using it in CML. The aim of this study is to describe our experience confronting this rare side effect and review the available data worldwide. Patients and Methods: It was a retrospective analysis conducted at a center from February 2002 to February 2015. This study was endorsed by our Institutional Review Board (IRB) and written consent was taken from all patients. Patients diagnosed as Philadelphia (Ph) chromosome-positive CML either in chronic phase (CP), accelerated phase (AP), or blastic crisis (BC) were included. There were a total of 1,576 patients with CML treated with imatinib during this period. Karyotyping and quantitative reverse transcriptase polymerase chain reaction (RT-qPCR) were done at the time of pancytopenia for all patients. Results: In total, 11 (males = 5, females = 6) patients met our inclusion criteria from 1,576 patients of CML. The median age was 58 years (range 32-76). Out of 11 patients 8, 2, and 1 patients were in CP, AP, and BC phases, respectively. The median time of administration of imatinib was 3.3 months (range 1.5-6). The average time of marrow recovery was 10.4 months (range 5-15). Two patients expired (one from septicemia and the other from intracranial hemorrhage). BCR-ABL transcripts level by RT-PCR revealed the existence of the disease in all patients. Conclusion: Imatinib is a very well-tolerated tyrosine kinase inhibitor (TKI), but is associated with persistent myelosuppression when used in older age, advanced phase of the disease, and treated previously. After confirming persistent marrow aplasia, the treatment is mainly supportive. It is striking that the disease is still persistent, which is confirmed by RT-PCR. There is no consensus regarding recalling imatinib at lower doses or the use of second-generation TKI (nilotinib, dasatinib) in these patients.

Impact of radical dose escalation by endoluminal brachytherapy and induction chemotherapy in the definitive treatment of locally advanced esophageal cancer - A retrospective study.

Background: The loco-regional recurrence rate remains the main concern in the treatment of esophageal cancer. However, there are controversial data regarding the benefit of dose escalation in the treatment of esophageal cancer. The study examines the implications of dose escalation with endoluminal brachytherapy after induction chemotherapy and definitive chemoradiation in cases of carcinoma esophagus. Material and Methods: Total 31 biopsy-proven patients with inoperable, locally advanced esophageal cancer of stage IIA-IIIB were enrolled from January 2006 till December 2018. All patients underwent two cycles of three weekly induction chemotherapy followed by definitive external beam radiotherapy of 45-50.4 Gray (Gy) at 1.8 Gy per fraction along with chemotherapy, followed by intraluminal brachytherapy boost of two fractions with 5 Gy each. Overall survival (OS) was censored at death or the last follow-up. Results: Of 31 patients, 26 (83.97%) received concurrent chemotherapy and 30 (96.77%) completed radiation therapy. At the end of 3 months, 10 (32.2%), 13 (41.9%), 5 (16.1%), and 3 (9.6%) had complete response, partial response, stable disease, and progression of the disease, respectively. Distal failure was seen in five (16.1%) cases. The median OS was 28 months. OS at 2 years and 5 years was 20 (64.5%) and 9 (28.3%), respectively. At the end of 3 months, 17 (54.8%) of patients had no dysphagia, four (12.9%) of patients had improvement of more than 2 points in dysphagia score, five (16.1%) of patients had no change in the score and five (16.1%) of the patients had worsening of the dysphagia score by 1 point. Median dysphagia-free survival was 10.7 months, eight (25.8%) developed dysphagia after the dysphagia-free interval and two (6.4%) had worsening of dysphagia after treatment. There were no reported grade III or grade IV acute toxicities. Conclusion: The protocol has shown an acceptable survival and dysphagia-free interval. The study suggests intraluminal brachytherapy with induction chemotherapy and definitive chemoradiation is a feasible option in locally advanced esophageal cancer.

Oxygen-induced hypercapnia: physiological mechanisms and clinical implications.

Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. The risk of hypercapnia is not restricted to COPD only; it has also been reported in patients with morbid obesity, asthma, cystic fibrosis, chest wall skeletal deformities, bronchiectasis, chest wall deformities, or neuromuscular disorders. However, the risk of hypercapnia should not be a deterrent to oxygen therapy in hypoxemic patients with chronic lung diseases, as hypoxemia may lead to life-threatening cardiovascular complications. Various mechanisms leading to the development of oxygen-induced hypercapnia are the abolition of 'hypoxic drive', loss of hypoxic vasoconstriction and absorption atelectasis leading to an increase in dead-space ventilation and Haldane effect. The international guideline recommends a target oxygen saturation of 88% to 92% in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and other chronic lung diseases at risk of hypercapnia.  Oxygen should be administered only when oxygen saturation is below 88%. We searched PubMed, EMBASE, and the CINAHL from inception to June 2022. We used the following search terms: "Hypercapnia", "Oxygen therapy in COPD", "Oxygen-associated hypercapnia", "oxygen therapy", and "Hypoxic drive". All types of study are selected. This review will focus on the physiological mechanisms of oxygen-induced hypercapnia and its clinical implications.

Isolated trigeminal neuralgia: An early weird presentation of carcinoma breast.

We report an interesting case of a 52-year-old postmenopausal female who presented with a 2-month history of headache, tingling sensation, and sharp shooting pain over the left face, followed by left facial paresthesia with pain over the maxillary region. Magnetic resonance imaging scan revealed presence of enplaque altered signal intensity soft-tissue lesion along the left 5th nerve from its origin at pons, and positron emission tomography with concurrent computed tomography showed a 2.9 cm × 2.6 cm intensely 18F-fluorodeoxyglucose-avid breast mass, in the upper outer quadrant of the right breast. Core-needle biopsy revealed infiltrating ductal carcinoma. Her estrogen receptor, progesterone receptor, and Her2-neu analysis suggested triple-negative breast cancer. She was managed with cranial radiotherapy and palliative chemotherapy. The patient responded very well to radiotherapy and chemotherapy with complete improvement in her neurological symptoms and now she is under regular follow-up for chemotherapy for 8 months without any subjective or objective progression of the disease. Isolated cranial neuropathy may be an early harbinger of metastatic breast cancer, so we should search for the primary malignancy. TNBC is associated with early central nervous system metastasis because of heterogeneity in the biology of the disease. Whole-brain radiotherapy and palliative chemotherapy are the best available treatment modalities.

SARS-CoV-2 variants of concern: a review.

The virus that causes severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) belongs to the genus Beta coronavirus and the family Coronaviridae. The SARS-CoV-2 virus is a positive sense, non-segmented single-strand RNA virus that causes coronavirus disease 2019 (COVID-19), which was first reported in December 2019 in Wuhan, China. COVID-19 is now a worldwide pandemic. Globally, several newer variants have been identified; however, only a few of them are of concern (VOCs). VOCs differ in terms of infectivity, transmissibility, disease severity, drug efficacy, and neutralization efficacy by monoclonal antibodies, convalescent sera, or vaccines. VOCs reported from various parts of the world include B.1.1.7 (Alpha), B.1.351 (Beta), B.1.617/B.1.617.2 (Delta), P.1 (Gamma), and B.1.1.529 (Omicron). These VOCs are the result of mutations, with some based on spike proteins. Mutations may also cause molecular diagnostic tests to fail to detect the few VOCs, leading to a delayed diagnosis, increased community spread, and delayed treatment. We searched PubMed, EMBASE, Covariant, Stanford variants database, and CINAHL from December 2019 to February 2022 using the following search terms: Variant of Concern, SARS-CoV-2, Omicron, etc. All types of research were chosen. All research methods were considered. This review discusses the various VOCs, as well as their mutations, infectivity, transmissibility, and neutralization efficacy.

Ramucirumab in Indian Patients with Advanced Gastric Cancer-Does Borderline Performance Status and Heavy Burden of Disease in Real World Practice Impact Clinical Benefit?

Vikas OstwalBackground Ramucirumab is considered a standard of care as second-line therapy (CT2) in advanced gastric cancers (AGCs). The aim of this study was to assess practice patterns and outcomes with ramucirumab among Indian patients with AGCs. Materials and Methods A computerized clinical data entry form was formulated by the coordinating center's (Tata Memorial Hospital) medical oncologists and disseminated through personal contacts at academic conferences as well as via email for anonymized patient data entry. The data was analyzed for clinical characteristics, response rates, and survival outcomes. Results A total of 26 physicians contributed data, resulting in 55 patients receiving ramucirumab and being available for analysis. Median age was 53 years (range: 26-78), 69.1% of patients had greater than two sites of disease, and baseline Eastern Cooperative Oncology Group's performance score (ECOG PS) ≥ 2 was seen in 61.8% of patients. Ramucirumab was used as monotherapy in 10.9% of patients, while the remaining 89.1% received ramucirumab combined with chemotherapy. Median event-free survival (EFS) and median overall survival (OS) with ramucirumab were3.53 months (95% CI: 2.5-4.57) and 5.7 months (95% CI: 2.39-9.0), respectively. Common class specific grade adverse events seen with ramucirumab included gastrointestinal (GI) hemorrhage (9.1% - all grades) and uncontrolled hypertension (Grade 3/4 - 3.6%). Conclusions Ramucirumab appears to have similar efficacy in Indian AGC patients when compared with real-world data from other countries in terms of median EFS, but OS appears inferior due to more patients having borderline ECOG PS and high metastatic disease burden. GI hemorrhages appear more common than published data, although not unequivocally related to ramucirumab.

Use of flow volume curve to evaluate large airway obstruction.

The flow volume loop (FVL) is a graphic display of airflow against lung volumes at different levels obtained during the maximum inspiratory and expiratory maneuver. It is a simple and reproducible method of lung function assessment. A narrative review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, EMBASE, Ovid MEDLINE and CINAHL databases were queried and reviewed for studies pertinent to the various FVLs abnormalities and their mechanisms from January 2020 to December 2020. We used the following search terms; flow-volume loop, upper airway obstruction, Obstructive airway disease, and spirometry.  Assessing the shape of the flow-volume loop is particularly helpful in diagnosing and localizing upper airway obstruction. They are also helpful in identifying bronchodilator response to treatment. Characteristic FVLs is also seen in patients with obstructive or restrictive lung disorders. Spirometry should be interpreted using the absolute values for flows and volumes as well as the flow volume and volume time curves.

COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A review.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus responsible for the pandemic coronavirus disease 19 (COVID-19). It has significant impact on human health and public safety along with negative social and economic consequences. Vaccination against SARS-CoV-2 is likely the most effective approach to sustainably control the global COVID-19 pandemic. Vaccination is highly effective in reducing the risk of severe COVID-19 disease. Mass-scale vaccination will help us in attaining herd immunity and will lessen the negative impact of the disease on public health, social and economic conditions. The present pandemic stimulated the development of several effective vaccines based on different platforms. Although the vaccine is safe and efficacious, rare cases of thrombosis and thrombocytopenia following the use of vaccination with the ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India) or the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) have been reported globally. This review focussed on the definition, epidemiology, pathogenesis, clinical features, diagnosis, and management of vaccine associated thrombosis.

COVID-19 and coagulopathy.

The SARS-CoV-2 is a new coronavirus responsible for the COVID-19 disease and has caused the pandemic worldwide. A large number of cases have overwhelmed the healthcare system worldwide. The COVID-19 infection has been associated with a heightened risk of thromboembolic complications. Various mechanisms are leading to the high thrombotic risk in COVID-19 patients such as inflammation, endotheliitis, hyperviscosity, and hypercoagulability. We searched PubMed, EMBASE, and CINAHL from January 2020 to December 2020. We used the following search terms: COVID-19, coagulopathy, and thrombosis. We reviewed the epidemiology, clinical features, mechanisms, and treatment of COVID-19-associated coagulopathy.

Severe headache presenting as an early sign of retroperitoneal para aortic paraganglioma.

BACKGROUND: Paraganglioma is a rare type of neuroendocrine tumor with the ability to secrete neuropeptide and catecholamines in excess. Sympathetic hyperactivity, severe persistent headache and hypertension is the most common clinical presentation of paraganglioma similar to pheocromocytoma. Case report We reported a case of 19 year old girl with severe headache and hypertension, from past 6 month. On further imaging evaluation for the headache, the computed tomography of the abdomen plus pelvis was suggestive of left pre para aortic paraganglioma measuring of 3.4 cm in diameter. Surgical excision of mass was done. Histopathological examination of surgical specimen was consistent with the diagnosis of paraganglioma. Patient is on regular follow up without any subjective or objective evidence of the disease. CONCLUSION: Retroperitoneal paraganglioma may be one of the causes for commonly occurring symptomatic headache, which is benign in nature, but possibility of transformation of malignant paraganglioma can occur. The surgical excision of mass is the treatment of choice.

Maxillary bone metastasis, as an early sign of breast cancer; an unusual & rare site of metastasis from the common cancer.

Oral cavity metastases are considered rare and represent approximately 1% of all oral malignancies. Due to their rarity and atypical clinical and radiographic appearance, metastatic lesions are considered a diagnostic challenge. In this article we present a rare, unusual & exceptional case of left maxillary mass which on further evaluation leading to diagnosis of left breast carcinoma with metastasis to isolated left maxillary bone. Sixty five year old postmenopausal woman of low socioeconomic status with good performance status presented with a 3 months history of progressive pain and swelling in the left maxillary region. Fine Needle Aspiration Cytology (FNAC) from the maxillary mass shows invasive ductal carcinoma. On further clinical, radiographic, and histopathological examination findings from the breast lesion confirmed the diagnosis of hormone receptor positive metastatic breast carcinoma. In view of painful metastatic maxillary lesion with breast disease she was managed with a palliative radiotherapy to the maxillary lesion and palliative chemotherapy with Doxorubicin-Cyclophosphamide and bhisphosphonate-Zolendronic acid. Patient responded very well to palliative radiotherapy and chemotherapy, in view of hormone receptor positive breast cancer, now she is on Tab. Anastrazole 1 mg once a day along with monthly Zolendronic acid injection since last 13 months without any symptoms of disease evolution. A high index of clinical thought of metastatic cancer to maxilla is necessary when evaluating patients who complain of maxillary pain and swelling without a history of pain or swelling in the head and neck & non-head and neck region. To the best of our knowledge, this is the first reported case of a metastatic isolated solitary maxillary bone metastasis presenting as an early sign of breast cancer.

Proximal Descending Thoracic Aortic Pseudoaneurysm Secondary to Pott's Spine.

Tuberculous pseudoaneurysm of the descending thoracic aorta is quite rare, life-threatening, and fatal if not diagnosed in time. This lesion exposes patients to a very high risk of unpredictable rupture. We describe a case of tuberculous pseudoaneurysm of the aorta in association with tuberculosis of the spine (Pott's spine). A 73-year-old man presented with a 2-month history of back pain. Chest roentgenography and contrast-enhanced computed tomography showed a descending thoracic aortic pseudoaneurysm with destruction of the fourth and fifth thoracic vertebrae (T4-T5). We suspected that the pseudoaneurysm was due to direct extension of tuberculous vertebral osteomyelitis. The patient was managed with antituberculous chemotherapy. The post-antitubercular therapy course was uneventful and he remained well 12 months after completion of treatment.

Tolerance of Radical Radiotherapy Among Elderly Head and Neck Cancer Patients.

Head and neck cancers usually occur in the elderly age group and about half of the cases occur at the age > 60 years with majority detected in an advanced stage with increased morbidity and decreasing compliance to therapy. Since there are limited data available for the adequate treatment of elderly head and neck cancer patients, we proposed a study to analyze tolerance and response based on age, site, modality of treatment received, and implication of nutrition vs weight loss during treatment. Fifty-five patients were enrolled in this study, which was conducted between November 2015 and April 2017, and those who met the eligibility criteria were evaluated with a detailed history and physical examination, and biochemical, pathological, and radiological investigations. Patients were staged based on TNM staging and treated as per the standard guidelines. Patients were assessed with the weekly routine blood investigation, weight loss, and toxicity. The response was assessed after 6 weeks and documented as per RECIST criteria. 52/55 (94.5%) patients completed the treatment, and 48/55 (92.3%) had a complete response at 6 weeks (p value 0.000) with a mean treatment duration of 46.67 days and mean weight loss of 5.44 kg with 55.4% having GR-II mucositis, 40% having GRIII mucositis at the time of completion of treatment. Sixty-eight percent having GRII and 38.2% having GR I dermatitis and 80% had moderate pain. Subgroup analysis was done based on age, site, and treatment modality. Patients were also assessed for nutrition vs weight loss. We concluded that elderly patients tolerate and respond well to radical treatment with acceptable toxicities; hence, age should not be a barrier to decide treatment.

COVID-19: a review.

The enduring epidemic outbreak which started in Wuhan city of China, in December 2019 caused by the 2019 novel coronavirus (COVID- 19) or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a dangerous and deadly Public Health disaster of International apprehension, with cases confirmed in several countries. This novel community health trouble is frightening the universe with clinical, psychological, emotional, collapse of health system and economical slowdown in each and every part of the world infecting nearly 200 countries. A highly virulent and pathogenic COVID-19 viral infection with incubation period ranging from two to fourteen days, transmitted by breathing of infected droplets or contact with infected droplets, belongs to the genus Coronavirus with its high mutation rate in the Coronaviridae. The likely probable primary reservoir could be bats, because genomic analysis discovered that SARSCoV-2 is phylogenetically interrelated to SARS-like bat viruses. The transitional resource of origin and transfer to humans is not known, however, the rapidly developing pandemic has confirmed human to human transfer. Approximately 1,016,128 reported cases, 211,615 recovered cases and 53,069 deaths of COVID-2019 have been reported to date (April 2, 2020). The symptoms vary from asymptomatic, low grade pyrexia, dry cough, sore throat, breathlessness, tiredness, body aches, fatigue, myalgia, nausea, vomiting, diarrhea, to severe consolidation and pneumonia, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction leading to death with case fatality rate ranging from 2 to 3%.

Pediatric chronic myeloid leukemia: A single-center experience.

BACKGROUND: The rationale of this study is to reveal the statistics of pediatric chronic myeloid leukemia (CML) patients. SUBJECTS AND METHODS: It is a retrospective analysis conducted to assess pediatric CML data from January 1998 to December 2014. There are 65 (3.2%) pediatric CML patients out of entire 2008 patients of CML. Data were analyzed regarding epidemiological characteristics, clinical presentations, response and side effects of imatinib, event-free survival, and overall survival of the pediatric CML patients. RESULTS: The median age of diagnosis was 11.84 years, and 76.9% patients were male and 23.07% patients were female. Sixty (92.3%) patients were in CML-chronic phase, 3 (4.6%) patients in CML-accelerated phase, and 2 (3.07%) patients in CML-blastic crisis. Most common initial symptoms and signs are weakness (60.0%), abdominal pain (55.38%), splenomegaly (100%), and hepatomegaly (86.5%). 67.3% of patients have white blood counts <100 × 109/L and 92.3% had platelets >150 × 109/L. In the initial months of 2002, imatinib was available and utilized in 54 patients. Of 54 patients, complete hematological response at 3 months, partial cytogenetic response at 6 months, complete cytogenetic response at 12 months, and major molecular response (MMR) at 18 months were 77.77%, 59.2%, 48.14%, and 40.74%, respectively. MMR at 36 months was 62.96% ( n = 34). Most common imatinib-related side effects are gastrointestinal upset and myelosuppression. CONCLUSION: Pediatric CML in India is comparable with Western countries regarding epidemiological characteristic, clinical presentations, and tolerance of imatinib. As there is a paucity of universal literature regarding pediatric CML (especially data from Southeast Asian region), this article may fill up that space.

Intraconal Metastasis Leading to Diagnosis of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the commontumor of the liver and the third most common cause of cancer-related mortality worldwide. Patients with HCC may have metastasis to different sites. Intrahepatic and extrahepatic metastases are found in (~50-75%). Lung and regional lymph nodes are the most commonly involved sites. Metastasis to bone, skin, and adrenal glands are rare. Orbit metastasis and intracranial invasion are extremely rare. We are presenting a case of HCC that metastasized to the orbital cavity. The patient presented with progressive proptosis of the eyeball with retrobulbar and intracranial invasion and involvement of the sub-scalp region. Based on the imaging findings, it was initially misdiagnosed as meningioma; however, histopathological examination of the biopsy specimen resulted in a definitive diagnosis of HCC metastasis. The present case reveals that the alternative diagnosis of metastasis must be considered when diagnosing retrobulbar lesions in patients with HCC.