Evaluating contralateral neck failure in patients with lateralized OPSCC treated with transoral robotic surgery and neck management based on pre-operative SPECT-CT lymphatic mapping.

BACKGROUND: Risk of contralateral nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) is relatively low, however, many OPSCC patients receive bilateral neck treatment. This study evaluates the oncological outcomes with management of the contralateral cN0 neck based on lymphatic mapping with single photon emission computed tomography (SPECT-CT). METHODS: Retrospective evaluation of patients with lateralized cT1-2 and contralateral cN0 OPSCC treated with primary surgery between December 2017 and October 2019. All patients underwent pre-operative lymphatic mapping using SPECT-CT. Clinical parameters including demographics, tumor characteristics and oncological outcomes were recorded. RESULTS: Thirteen patients underwent primary site resection with transoral robotic surgery (TORS) and ipsilateral neck dissection with or without adjuvant therapy. Twelve patients (92.3%) had ipsilateral drainage on SPECT-CT, whereas 1 (7.7%) patient had bilateral neck lymphatic drainage. Four patients (30.8%) underwent post-operative radiation therapy (PORT). Three patients with unilateral drainage on SPECT-CT underwent PORT with unilateral neck irradiation, and 1 patient with bilateral drainage underwent PORT with bilateral neck irradiation. Seven (53.8%) patients were staged as pT1, 6 (46.2%) patients as pT2, 6 (46.2%) patients were pN0, 3 (23.1%) patients were pN1, 1 (7.7%) patient was pN2a for and 3 (23.1%) patients were N2b. The median distance of the tumor from midline was 1.05 cm (0.0-1.58). Primary sites included tonsil (n = 10, 76.9%) and tongue base (n = 3, 23.1%). The median follow-up time was 15.4 months. All patients were disease free at the latest follow-up with no contralateral neck failures. CONCLUSIONS: Pre-operative mapping of lymphatic drainage in early stage OPSCC with SPECT-CT is a promising tool which can reduce treatment to the contralateral neck potentially without compromising oncological outcomes.

Comparison of the diagnostic utility of 99mTc-PSMA scintigraphy versus 68Ga-PSMA-11 PET/CT in the detection of metastatic prostate cancer and dosimetry analysis: a gamma-camera-based alternate prostate-specific membrane antigen imaging modality.

OBJECTIVE: The present study was performed for head-to-head comparison between 68Ga-prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) and 99mTc-PSMA whole-body and regional single-photon emission computed tomography (SPECT)/CT for the detection of prostate cancer metastases. METHODS: Ten patients with metastatic prostate cancer underwent 99mTc-PSMA whole-body scan after intravenous injection of 230-330 MBq 99mTc-PSMA. Anterior and posterior whole-body images were acquired at 10 min, 2, 4 and/or 5/6 h post-injection. Additional SPECT/CT images were acquired for the involved sites, where planar images did not clearly identify the metastatic sites. All patients also underwent whole-body 68Ga-PSMA PET/CT and the results between the two techniques were compared for the detection of the metastatic lesions. Dosimetry analysis of the 99mTc-PSMA studies was performed using the MIRD-OLINDA approach. RESULTS: 68Ga-PSMA PET/CT detected lesions in all 10 patients, whereas 99mTc-PSMA imaging detected lesions in 9/10 patients. 68Ga-PSMA PET/CT imaging identified a total of 112 PSMA avid metastatic lesions compared to 57 (51%) lesions on 99mTc-PSMA imaging. Eighteen out of 57 lesions were detected only on delayed 99mTc-PSMA imaging at 4 h and/or 6 h. The regional 99mTc-PSMA SPECT detected 51/83 (61.0%) lesions seen on 68Ga-PSMA PET/CT. The dosimetry results demonstrated that 99mTc-PSMA provided organs' radiation absorbed/effective doses comparable with 99mTc-PSMA imaging. CONCLUSION: Whole-body 99mTc-PSMA combined with regional SPECT/CT could be a potential alternative to 68Ga-PSMA PET for the detection of the advanced stage metastatic prostate cancer and for response evaluation to PSMA-based targeted therapies.

Lymphatic mapping with SPECT-CT for evaluation of contralateral drainage in lateralized oropharyngeal cancers using an awake injection technique.

BACKGROUND: Risk of contralateral nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) is currently based on clinical risk factors. We propose lymphatic mapping with single photon emission computed tomography (SPECT-CT) for tumor-specific delineation of lymphatic drainage to guide treatment. METHODS: Retrospective review of lymphatic drainage patterns in cT1-2 OPSCC and contralateral cN0 neck with a nonoperative, awake injection of 99 m-Tc sulfur colloid and SPECT-CT. RESULTS: Ten patients were reviewed. Primary sites included tonsil (n = 8, 80%) and tongue base (n = 2, 20%). All patients tolerated awake injections with no complications. Nine patients (90%) demonstrated satisfactory migration of radiotracer to neck node(s) with seven (78%) to the ipsilateral lateral neck, one (11%) to the ipsilateral lateral neck and retropharynx, and one (11%) to bilateral lateral neck nodes. CONCLUSIONS: Characterization of lymphatic drainage in OPSCC is feasible using a nonoperative injection technique and SPECT-CT. Drainage to the contralateral neck is rare, warranting further study to tailor treatment appropriately.

Changes in airway dimensions after robot assisted surgeries in steep Trendelenburg position.

Robotic surgeries in the extreme Trendelenburg position can lead to changes in the airway dimensions. We conducted a prospective, observational trial to explore the use of ultrasound to quantify these changes in the airway dimensions and identify the factors associated with it. Fifty-two American society of Anaesthesiologists physical status I-II patients between 18 and 70 years of age of either sex scheduled to undergo robot assisted urological procedures in steep Trendelenburg position were enrolled. Anterior soft tissue thickness at the level of hyoid bone and vocal cords, tongue thickness, Malampatti grading and neck circumference were measured at predefined postoperative intervals in the immediate postoperative period, at 2-, 6- and 12-h period postoperatively. Linear stepwise regression analysis was done to explore the factors associated with change in anterior tissue thickness immediately after surgery. The mean difference (95%; CI) in the anterior soft tissue thickness in the immediate postoperative period at the level of hyoid was 0.023 (0.029-0.016) cm, p < 0.001 and at level of vocal cords was - 0.012 (- 0.017 to - 0.008) cm, p < 0.001 from the baseline. There was a significant increase in tongue thickness (0.002), Mallampati score (p = 0.002) and neck circumference (p < 0.001) in immediate postoperative period. The change in anterior tissue thickness at the level of hyoid was affected by total intraoperative fluids used (r = 0.602, p < 0.001), airway trauma (r = 0.275, p = 0.002) and duration of surgery (r = 0.243, p = 0.025). Significant changes in airway dimensions after robotic surgeries in Trendelenburg position persist till 2 h in the postoperative period which warrant vigilant monitoring for any airway compromise during this period.

Palatal Perforation: A Rare Complication of Postanesthetic Necrosis.

The everyday practice of dentistry relies heavily on achieving adequate local anesthesia. Even though the safety record of local anesthetic agents is high, complications do occur. Palate is a favorable site for soft-tissue lesions. Various factors such as direct effects of the drug, blanching of the tissues during injection, relatively poor blood supply, and reactivation of the latent forms of herpes can all promote to tissue ischemia and a lesion in the palate. Among various complications, anesthetic necrotic ulcer is a rare and uncommon condition occurring mostly in the hard palate possibly after a local anesthetic infiltration. The ulceration is often deep and shows spontaneous but delayed healing. If proper treatment is not instituted on time, the necrosis can reach deep into the bone causing sequestrum formation and ultimately leading to palatal perforation. Here, we report a case of palatal perforation in a male patient followed by surgical interventions and follow-up.

Incidence of Oral Lichen Planus in Perimenopausal Women: A Cross-sectional Study in Western Uttar Pradesh Population.

BACKGROUND: Hormonal fluctuations during menopause lead to endocrine changes in women, especially in their sex steroid hormone production. Studies have documented the role of estrogen and progesterone (Pg) on autoimmune disorders such as multiple sclerosis, systemic lupus erythematosus, and rheumatoid arthritis. Lichen planus (LP), an autoimmune disorder, seen frequently in perimenopausal women, may also get affected by sex steroid hormones, but no direct relationship has been established yet. AIM: The aim of this study is to find the incidence of oral LP (OLP) in perimenopausal women and evaluate the factors associated with it. MATERIALS AND METHODS: This cross-sectional study was conducted over a period of 1 year. All the perimenopausal women (44.69 ± 3.79 years) who came to the dental outpatient department were evaluated for the presence of LP and various factors associated with it. Depression Anxiety Stress Scale-21 questionnaire was used for psychometric evaluation of perimenopausal women. RESULTS: According to our study, incidence of LP in postmenopausal women was 10.91%, which is higher than incidence of LP in general population, i.e., 0.5% to 2.0%. Incidence of LP increased with the severity of depression in perimenopausal women (P = 0.000). CONCLUSION: The incidence of OLP is higher in perimenopausal women than in general population and increases significantly with increase in the severity of depression. LP in perimenopausal women can be mediated by declined level of estrogen and Pg directly or indirectly through causing depression that can trigger LP.

Implementing a Cervical Sentinel Lymph Node Biopsy Program: Quality Improvement in Gynaecologic Oncology.

OBJECTIVE: Sentinel lymph node (SLN) biopsy is becoming a reasonable alternative to pelvic lymphadenectomy in early-stage cervical cancer. It is therefore imperative that centres without prior experience are able to successfully implement the procedure. The objectives of the current study were to (1) describe the process of implementing an SLN biopsy program with a novel peer mentorship component and (2) assess post-program quality improvement metrics, including SLN detection rate (DR) and diagnostic parameters. METHODS: An institutional SLN biopsy protocol was developed collaboratively by gynaecologic oncology, nuclear medicine, and pathology departments at University Health Network, Toronto, Ontario. All decisions were based on the best evidence available. Newly diagnosed, early-stage cervical cancer patients undergoing primary surgery were then recruited prospectively for SLN biopsy with combined technique, followed by pelvic lymphadenectomy to evaluate key quality indicators, including SLN DR, sensitivity, and negative predictive value. Surgeons with previous SLN biopsy experience mentored surgeons unfamiliar with the technique. Interim analyses and multidisciplinary rounds were regularly carried out to identify failures of technique or protocol. RESULTS: Thirty-nine patients (median age 42) were enrolled in the study between August 2010 and February 2014. The median number of SLNs and total pelvic lymph nodes removed per patient were 3 and 19, respectively. SLN DRs were 92% per patient (36/39), 88.5% per hemipelvis (69/78), and 85% bilaterally (33/39). SLN biopsy correctly identified seven of eight hemipelvises with nodal metastases, yielding a sensitivity of 88% (95% CI 0.47 to 1.00) and a false negative rate of 12% (95% CI 0 to 0.53). Surgeons undergoing peer mentorship (n = 3) performed as effectively (DR 100%) as surgeons (n = 2) with prior experience (DR 85%). CONCLUSIONS: This study provides a model upon which other centres can adopt and validate cervical SLN biopsy. High SLN DRs and accurate identification of lymph node metastases can be achieved by focusing on multidisciplinary collaboration, knowledge translation with creation of evidence-based protocols, peer mentorship, and ongoing quality control.

Indian Council of Medical Research Consensus Document for the Management of Non-Hodgkin's Lymphoma (High Grade).

This consensus document is based on the guidelines related to the management of Non Hodgkin's Lymphoma (High grade) in the Indian population as proposed by the core expert committee. Accurate diagnosis in hematolymphoid neoplasm requires a combination of detailed history,clinical examination, and various investigations including routine laboratory tests, good quality histology section (of tumor and also bone marrow aspirate/biopsy), immunostaining, cytogenetic and molecular studies and radiology investigations. The staging system used for adult high grade lymphomas is based on the Ann Arbor system and includes various parameters like clinical, haematology, biochemistry, serology and radiology. Response should be evaluated with radiological evaluation after 3-4 cycles and at the end of treatment based on criteria including and excluding PET. Treatment of high grade lymphomas is based on histologic subtype, extent of disease, and age of the patient. Autologous stem cell transplantation after high dose chemotherapy is effective in the treatment of relapsed NHL. Newer RT techniques like 3 dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) can significantly reduce radiation doses to surrounding normal tissues in lymphoma patients. Patients should be followed up every 3 to 4 months for the first 2 years, followed by 6 monthly for the next 3 years and then annually.

Roles of serum uric acid, prolactin levels, and psychosocial factors in oral lichen planus.

Free radicals play important roles in the mechanisms underlying lichen planus (LP). Uric acid (UA) is an important anti-oxidant in plasma. Prolactin (PRL) is an immunomodulatory hormone that may promote LP, as has been documented in other autoimmune disorders, such as systemic lupus erythematosus, rheumatoid arthritis, and psoriasis. PRL has multiple immune-stimulatory effects and promotes the development of such autoimmune disorders. Prolactin and uric acid may serve as biomarkers of disease activity in lichen planus. The aim of the present study was to evaluate the roles of depression, stress, and anxiety in LP, as well as serum levels of UA and PRL as potential biomarkers of disease activity and compare these findings with those of the control group. Thirty-nine patients clinically diagnosed with oral LP (study group) and 39 age- and sex-matched controls (control group) were selected in this study. Serum UA and PRL levels were measured. The Depression Anxiety Stress Scale-21 was used for psychometric evaluation of LP patients and controls. Serum UA level was found to be significantly higher in the control group as well as during the remission phase of disease in the study. There was no significant difference in serum PRL levels between cases and controls. Depression and stress scores were higher in the study group.

Effect of chemotherapy on the impact of FDG-PET/CT in selection of patients for surgical resection of colorectal liver metastases: single center analysis of PET-CAM randomized trial.

The largest randomized controlled trial (RCT) on the effect of FDG-PET on surgical management for metastatic colorectal adenocarcinoma to liver ("PET-CAM") reported only a modest change in surgical management (8%). PURPOSE: To explore the relationship between prior chemotherapy and detection of metastatic disease on PET in patients from PET-CAM. Secondary aim: to determine whether centralized imaging interpretation could have impacted trial results. METHODS: The study included 120 patients from a single institution. Local PET interpretation (PET-L) was recorded from the original database. Retrospective PET interpretation was performed independently by at least one additional reader (PET-C). The presence of extrahepatic disease (EHD) and significant additional liver metastases (=SALM), defined as metastases not originally planned for resection, was recorded. Patients were stratified to responders to recent chemotherapy (Group R) versus all others (Group O) according to surgical pathology and RECIST criteria. RESULTS: Thirty-seven of 50 patients who received recent chemotherapy (<90 days) were responders (Group R). EHD was present in 30/120 (25%) patients. There was no difference in detection of EHD on PET-L (7/37;18.9%), PET-C (7/37;18.9%), and CT (4/37;10.8%) for Group R (p = 0.375), but in Group O more EHD was detected on both PET-L (15/83;18.1%) and PET-C (22/83;26.5%) than CT (8/83;9.6%); p = 0.039 and p < 0.001, respectively. For the entire cohort, PET-L and PET-C detected EHD and/or SALM not reported on CT in 14 (11.7%) and 22 (18.3%) patients. CONCLUSION: The impact of recent chemotherapy on detection of colorectal metastases with PET suggests that the utility of PET in patient selection for liver resection in the prior PET-CAM-RCT may have been underestimated.

FDG PET/CT Response Assessment Criteria for Patients with Hodgkin's and Non-Hodgkin's Lymphoma at End of Therapy: A Multiparametric Approach.

PURPOSE: Based on the International Harmonization Project (IHP) criteria, positron emission tomography (PET) response assessment of residual nodal masses in patients with lymphoma after completion of therapy is performed visually using mediastinal blood pool as the reference. The primary objective of this study was to define the optimal reference for PET response assessment. Secondary aim was to assess if morphological criteria on computed tomography (CT) may improve performance of PET. METHODS: This institutional review board approved retrospective study included 137 patients, with Hodgkin's (n = 43) or non-Hodgkin's lymphoma (n = 94) assessed for residual masses (n = 180) after completion of therapy with pathology and clinical and imaging surveillance data (mean, 19 months) as the standard of reference. Two readers independently assessed response by IHP and Deauville criteria. The addition of morphological parameters on CT was assessed in relation to therapy response. RESULTS: Based on the standard of reference, 36 patients (26.3 %) had residual lymphoma. For IHP and Deauville criteria, sensitivity, specificity and accuracy were 97.2 %, 97.2 % (p = 1); 79.2 %, 92.1 % (p < 0.001); and 83.9 %, 93.4 % (p = 0.001), respectively. Of the morphological parameters assessed, only change in size over course of therapy was significant (p < 0.003) and improved specificity for IHP-based interpretation to 90.4 % (p = 0.008). CONCLUSIONS: Using liver as the visual reference to determine PET positivity for lymphoma patients being assessed for residual masses at the end of therapy improves specificity, yet maintains the high sensitivity of PET in identifying residual disease. The addition of change in size after therapy improves specificity of PET when using IHP-based but not Deauville-based interpretation.

Unusual intense fluorodeoxyglucose uptake in the intercostal muscles due to severe shortness of breath in a patient with heart failure.

We present a case of unusually intense Fluorodeoxyglucose uptake in the intercostal muscles during a Fluorodeoxyglucose positron emission tomography (FDG-PET). We hypothesized that severe left ventricular failure causing the patient to be short of breath during the study in association with insulin injection as part of study protocol led to the intense uptake of FDG in the respiratory muscles causing such an unusual appearance.

Factors Determining Periprocedural and Long-term Complications of High Risk Carotid Artery Stenting.

BACKGROUND AND PURPOSE: Carotid artery stenting (CAS) has been, historically, an alternative to open endarterectomy (CEA) for stroke prevention in high risk patients with carotid atherosclerosis. We sought to determine the rates of periprocedural and long-term stroke or death and the risk factors for complications after CAS in our high risk patient population. METHODS: Clinical and treatment variables of consecutive CAS procedures performed between 2002 and 2011 were analyzed. Using univariate and multivariate logistic regression analyses we examined how patient characteristics influenced outcomes and changes in modified Rankin Score (mRS). RESULTS: In 152 patients, the composite total of periprocedural death, stroke, transient ischemic attack (TIA) and myocardial infarction (MI) rate was 3.95% (6/152). Chronic kidney disease (CKD) was strongly associated with periprocedural complications (p<0.001). Coronary artery disease/peripheral vascular disease (CAD/PVD) (p=0.03), dyslipidemia (p=0.02), CKD (p=0.01), and contralateral internal carotid artery stenosis (p=0.02) were non-modifiable risk factors for mRS increase. There were 25 deaths, 8 strokes, 11 TIAs, and 1 MI (mean follow-up 38.4 months, range 0-116 months). The presence of CAD/PVD (p=0.009) and dyslipidemia (p=0.002) were significantly associated with long-term complications. CONCLUSION: CAS was performed with low periprocedural complications in high-risk patients. Our rates compare very favorably to large-scale trials that have ideal patients. This data encourages the consideration of CAS in patients considered high risk for CEA and provides possible patient characteristics (CKD) to help with periprocedural risk stratification.

Nimotuzumab plus chemotherapy versus chemotherapy alone in advanced non-small-cell lung cancer: a multicenter, randomized, open-label Phase II study.

BACKGROUND: The purpose of this study was to evaluate the safety and efficacy of nimotuzumab in combination with chemotherapy (docetaxel and carboplatin) versus chemotherapy alone in patients with stage IIIB/IV non-small-cell lung cancer. METHODS: This multicenter, open-label, Phase II study randomized 110 patients to receive nimotuzumab plus chemotherapy (nimotuzumab group) or chemotherapy alone (control group), and comprised concomitant, maintenance, and follow-up phases. Nimotuzumab 200 mg was administered once weekly for 13 weeks during the first two phases with four cycles of chemotherapy and docetaxel 75 mg/m(2) and carboplatin (area under the curve 5 mg/mL*min) every 3 weeks for a maximum of four cycles during the concomitant phase. The primary endpoint was objective response rate (sum of complete response and partial response). Secondary endpoints, ie, overall survival and progression-free survival, were estimated using the Kaplan-Meier method. Efficacy was evaluated on the intent-to-treat and efficacy-evaluable sets. Safety was assessed from adverse event and serious adverse event data. RESULTS: The objective response rate was significantly higher in the nimotuzumab group than in the control group in the intent-to-treat population (54% versus 34.5%; P=0.04). A complete response and partial response were achieved in 3.6% and 50% of patients, respectively, in the nimotuzumab group, and in 4% and 30.9% of patients, respectively, in the control group. No significant differences in median progression-free survival and overall survival were observed. Safety profiles were comparable between the two groups. CONCLUSION: Nimotuzumab plus chemotherapy significantly improved the objective response rate as compared with chemotherapy alone. The combination was safe and well tolerated in patients with stage IIIB/IV non-small-cell lung cancer.

Supplemental tooth in primary dentition.

An extra tooth causing numerical excess in dentition is described as supernumerary tooth, and the resultant condition is termed as hyperdontia. Hyperdontia is more commonly seen in the permanent dentition than primary one. Supernumerary tooth which resembles tooth shape and supplements for occlusion is called as supplemental tooth. We present a case with supplemental tooth in primary dentition.

A multilocular radiolucency of mandible as the first evidence of multiple myeloma: A clinico-radiographic case report.

The incidence of multiple myeloma (MM) affecting the jaws is 30% and on rare occasions the oral involvement can be the first indication of the disease. Authors report a case of MM in a 40-year-old woman who presented with a multilocular radiolucent lesion in the left mandible initially mistaken as an ameloblastoma. Conventional radiographs revealed a multilocular lesion on the molar region. Computed tomography (CT) and 3 dimensional CT revealed lytic, space occupying lesion perforating the inferior cortex. Magnetic resonance imaging (MRI) revealed a hypointense lesion on T1 weighted image and hyperintense lesion on T2 weighted image. Histopathological and lab investigations lead to the diagnosis of MM. MRI is superior in depicting the size of the lesion as compared to CT and conventional radiographs.

The radiological versatility of fibrous dysplasia: An 8-year retrospective radiographic analysis in a north Indian population.

OBJECTIVE: The aim of this study was to examine the clinical and radiographic presentation of fibrous dysplasia through an 8-year retrospective study in patients who reported to the outpatient unit of the Kothiwal Dental College and Research Centre, Moradabad. MATERIALS AND METHODS: The clinical file records and radiographs of the patients who reported to the outpatient clinic in the Department of Oral Medicine and Radiology were retrospectively reviewed for histopathologically diagnosed fibrous dysplasia. A detailed analysis of the clinical and radiographic features of the 14 cases retrieved was carried out. RESULTS: Almost all the patients presented with a complaint of swelling on the side of the face. The maxilla was more frequently involved than the mandible. The most common radiographic pattern observed was the ground-glass appearance, followed by orange peel, cotton wool, sunray and thumb print appearance, which leads to a perplex differential diagnosis. CONCLUSION: Awareness of the versatile features of fibrous dysplasia evident through this study is essential in the accurate diagnosis and proper treatment planning of such lesions.

Meteorological influences on the incidence of lichen planus in a north Indian population.

Lichen planus is a chronic, autoimmune, mucocutaneous disease that shows differences in clinical presentation at different times of the year. The present retrospective study was conducted to clarify the meteorological factors that influence the incidence of lichen planus, as well as the general features and clinical presentation of this condition during three consecutive years, 2008, 2009, and 2010, in Moradabad district (Western Uttar Pradesh, India). The study group comprised 1,355 patients extracted from the records of the outpatient department of Kothiwal Dental College Research Centre and Hospital, who were clinically diagnosed as having lichen planus during this three-year period. The highest number of patients (735) were recorded in summer, and the lowest (56) in winter. Females were affected more often, and psychosocial influences were also evident. There were significant differences in the incidence of lichen planus in different seasons, and the summer peak was attributable to the intensity of sun exposure (actinic lichen planus and summertime lichen planus).