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   2013| April-June  | Volume 2 | Issue 2  
    Online since June 19, 2013

 
 
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ORIGINAL ARTICLES
A prospective randomized controlled trial to study the role of sulfasalazine in prevention of acute gastrointestinal toxicity associated with concurrent chemoradiation in carcinoma cervix
Santanu Pal, Shyam Sundar Adhikary, Biswamit Bhattacharya, Joydeep Basu, Tanmoy Ghosh, Niladri Behari Patra
April-June 2013, 2(2):118-121
DOI:10.4103/2278-0513.113633  
Background: The primary aim of the study was to evaluate the effectiveness of sulfasalazine in reducing the incidence of acute radiation-induced enteritis in carcinoma cervix patients receiving pelvic external beam radiotherapy along with concurrent cisplatin-based chemotherapy. Materials and Methods: Between November 2011 and July 2012 a total of 98 patients of locoregionally advanced carcinoma of cervix (49 each in study and control arms) were enrolled in this study. Patients in both the arms were treated with whole pelvis external beam radiotherapy with total dose of 50 Gy in conventional fractionation. Along with this inj. cisplatin was given concurrently at the dose of 40 mg/m 2 of body surface area every week during radiation for 5 weeks. Concurrent chemoradiation was followed by brachytherapy after a gap of 2 weeks. Patients in the study arm also received tablet sulfasalazine 1,000 mg orally twice daily from the day of starting of radiotherapy to 1 week after completion of treatment. Weekly follow-up of all patients to assess acute toxicities was done using common toxicity criteria version 4.0 (CTC v4.0) toxicity scores. Data analysis was carried out by SPSS version 20.0 software. Results: Incidence of grade II or higher grade, lower gastrointestinal toxicity was 19.14% (09/47) in study arm and 41.66% (20/48) in control arm which was statistically significant (P = 0.017). Conclusion: The study shows that sulfasalazine can significantly reduce the acute radiation-induced diarrhea (ARID) in patients undergoing whole pelvis external beam radiotherapy for carcinoma cervix. The drug is safe, cheap, and readily available.
  4 2,320 120
Fine-needle aspiration cytology and biopsy in hepatic masses: A minimally invasive diagnostic approach
Jitendra G Nasit, Viren Patel, Biren Parikh, Manoj Shah, Kajal Davara
April-June 2013, 2(2):132-142
DOI:10.4103/2278-0513.113636  
Aims and Objective: To evaluate the diagnostic sensitivity, usefulness and limitations of fine-needle aspiration cytology (FNAC) and fine-needle aspiration biopsy (FNAB) in the diagnosis of hepatic masses. Materials and Methods: FNAC was performed on 150 cases of hepatic masses under guidance of ultrasound or computed tomography (CT) scan. Adequate diagnostic aspirates were obtained in 147 cases (98.0%). Smears were stained with hematoxylin and eosin (H and E), and Papanicolaou stains. FNAB was obtained from the same 149 cases (except one) and stained with HE stain. The hepatic masses were categorized into benign, malignant and inflammatory groups. Results: Out of 150 hepatic masses, 3.3% were benign, 94.26% were malignant and 2% were inflammatory lesions. FNAC and FNAB were unsatisfactory for evaluation in 3 out of the 150 cases (2%) and 6 out of 149 cases (4.02%), respectively. Correct cytological diagnoses were achieved in 129 out of the 150 cases (diagnostic sensitivity: 86%). FNAB gave satisfactory results in 143 out of 149 cases (diagnostic sensitivity: 95.77%). Cytological diagnoses of 21 cases were not consistent with histology (false negativity: 14%). Cyto-histological correlation showed 87.32% diagnostic sensitivity of FNAC for malignant tumors, whereas benign tumors posed maximum diagnostic problems, with sensitivity of 40%. This difference was statistically significant (P < 0.05). FNAB showed a statistically significant difference (P < 0.05) compared with FNAC in the diagnosis of benign and malignant hepatic masses. FNAC showed 100% diagnostic sensitivity for inflammatory lesions. Conclusion: Malignant tumors of liver can be confidently diagnosed on FNAC. However, FNAC has a few limitations and diagnostic challenges in benign lesions, well-differentiated and poorly differentiated hepatocellular carcinoma, and metastatic carcinoma. Microhistology by FNAB allows architectural, cellular and immunohistochemical evaluation. To obtain maximum diagnostic information with reduction of indeterminate reports, a combined approach of FNAC and FNAB with clinical findings, tumor markers and ancillary techniques should be used.
  3 10,766 206
Effects of pre-existing undernutrition on treatment-related complications and treatment outcomes in children with acute lymphoblastic leukemia: A tertiary care center experience
Amrita Roy, Aramita Saha, Sohini Chakraborty, Subrata Chattopadhyay, Prabir Kumar Sur
April-June 2013, 2(2):143-148
DOI:10.4103/2278-0513.113637  
Background: Our study aimed to assess the influence of undernutrition on treatment tolerance, treatment-related complications, and treatment outcomes in acute lymphoblastic leucomia (ALL) patients during induction and maintenance phase of chemotherapy and subsequent follow-up visits. Materials and Methods: This retrospective, cohort study was conducted between January 2005 and September 2012 in the Departments of Pediatrics and Radiation Oncology in a tertiary care Medical College and Hospital of Eastern India. Using weight-for-age Z scores (WHO), we divided the 159 ALL patients into 4 groups: Group 1 without malnutrition, Group 2 with mild undernutrition, Group 3 with moderate undernutrition, and Group 4 with severe malnutrition. Data regarding blood counts, hematological support, bone marrow remission status and complications during treatment, and follow-up records were analyzed and compared to find out the impact of undernutrition on treatment tolerance and outcomes in different groups. Results: During the intensive phase of chemotherapy treatment, tolerance was assessed by the nadir of absolute neutrophil count and hemoglobin which fell significantly in moderate and severe malnutrition group. Significantly, more packed red blood cell support and platelet transfusions were required by those two groups P < 0.002 and P < 0.001, respectively. The incidence of febrile neutropenia was significantly more in severe malnutrition group (P < 0.001). Ninety-eight (61.63%) patients could not complete chemotherapy within the specified 145-day period of which 23 (76.67%) patients was of severe malnutrition group (P < 0.002). Remission after induction has shown declining trend with more undernutrition. A total of 24 patients relapsed in spite of bone marrow remission which was proportionately more from moderate and severe malnutrition group. During the 5-year follow-up, 20 patients died which was proportionately more in Group 3. Conclusion: Undernutrition adversely affect the final outcome, treatment tolerance, and treatment complications in children with ALL. So, baseline malnutrition should be considered as an important prognostic factor in therapeutic decision of ALL.
  3 2,401 208
REVIEW ARTICLES
Myoepithelial cells: Current perspectives in salivary gland tumors
C Pramod Redder, V Suresh Kandagal, Nupura Vibhute, Pramod S Ingaleshwar, Sharan J Shetty, Sameer Ahamad
April-June 2013, 2(2):101-105
DOI:10.4103/2278-0513.113624  
Myoepithelial cells are normal constituent of the salivary acini and smaller ducts, and are found between the epithelial cells and the basement membrane. Microscopic examination shows that myoepithelial cells are thin and spindle-shaped and situated between the basement membrane and epithelial cells. Ultrastructurally they possess a number of cytoplasmic processes that extend between and over the acinar and ductal-lining cells. They display features of both smooth muscle and epithelium, such as numerous microfilaments with focal densities in the cytoplasmic processes, and desmosomes which attach the myoepithelial to the epithelial cells. Neoplastic myoepithelial cells in both benign and malignant tumors can take several forms, including epithelioid, spindle, plasmacytoid, and clear, and this variability largely accounts for difficulties in histopathological diagnosis. This review article highlights the role of myoepithelial cells in salivary gland tumors.
  3 13,498 566
CASE REPORTS
Delayed reversible methotrexate-induced leucoencephalopathy in a four-year-old child with acute lymphoblastic leukemia
Amrita Roy, Neelakshi Ghosh, Aramita Saha, Somenath Chatterjee
April-June 2013, 2(2):160-162
DOI:10.4103/2278-0513.113642  
Intravenous/intrathecal methotrexate (MTX) has been implicated as a major cause of treatment-related neurotoxicity particularly leukoencephalopathy in children with hematological malignancy. We report a 4-year-old boy who presented with apathy and aphasia for 1 day while on the maintenance-phase chemotherapy according to MCP 841 protocol. MRI of brain revealed bilateral symmetrical FLAIR hyperintensities in caudate and putaminal region with FLAIR hypersignal in subcortical U-fiber in left frontal lobe consistent with MTX-induced toxic leucoencephalopathy. There was spontaneous resolution of symptoms within 1 week of onset. So, in Pre-B acute lymphoblastic leukemia patients with subtle neurological deficit, this diagnosis should be kept in mind and further treatment with MTX should be carefully decided.
  1 3,273 114
Extramedullary plasmacytoma of the orbit: A rare case
Subrata Chattapadhyay, Aramita Saha, Anindya Mukherjee, Mohammad Azam
April-June 2013, 2(2):163-165
DOI:10.4103/2278-0513.113643  
Solitary orbital plasma cell neoplasm in the absence of multiple myeloma is very rare. We present here a case report of extramedullary plasmacytoma of the right orbital soft tissue in a 50-year-old Indian woman whose thorough diagnostic workup was negative for multiple myeloma. The patient presented with gradually increasing proptosis, swelling, and visual disturbances of the right eye for past one and half years. Computed tomography (CT) scan of the orbit revealed lobulated, mildly enhancing soft tissue lesion in the supero-lateral aspect of right orbit without intracranial extension. Pathological report revealed a plasma cell neoplasm and immunohistochemistry was positive for CD138, CD20, CD 79a, PAX-5. Complete skeletal survey and bone marrow examination report were normal. So, normal skeletal survey, absence of bone marrow involvement, absence of Bence-Jones protein, no anemia, no hypercalcemia, no renal disease, normal level of immunoglobulins all exclude the diagnosis of multiple myeloma. Since the visual acuity of the patient is well-preserved, so we have planned to treat her with local radiotherapy alone with 50 Gy over 5 weeks.
  1 1,598 149
Extensive squamous metaplasia with cystic change in pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology
Jitendra G Nasit, Gauravi Dhruva
April-June 2013, 2(2):166-169
DOI:10.4103/2278-0513.113644  
Pleomorphic adenoma (PA) is the most common salivary gland tumor, frequently affects the parotid gland. Histological diversities are common as PA may show mucous, sebaceous, oncocytic cells, and squamous metaplastic cells. Squamous metaplasia rarely results in formation of extensive keratin-filled cyst lined by squamous epithelium. This can be mistaken for malignancy, like squamous cell carcinoma and mucoepidermoid carcinoma on cytological interpretation, due to limited and selective sampling. Here, we report a case of slowly enlarging parotid mass in a 70-year-old male. Cytological smears revealed moderately atypical squamous cells, clumps of keratin material, necrosis, inflammatory cells and macrophages along with bland epithelial and myoepithelial cell in fibromyxoid stroma. Cytological diagnosis of squamous cell carcinoma ex-pleomorphic adenoma was suspected. Subsequent resection showed pleomorphic adenoma, with extensive squamous metaplasia and cystic change on histology. There was no evidence of squamous cell carcinoma. The cytopathology findings are probably related to ischemic infarction, which mimic malignancy. This case emphasizes the need for a cautious and systematic approach in the cytological interpretation of cystic pleomorphic adenoma with metaplastic epithelial changes. We discuss the pitfall in the cytological diagnosis including differential diagnosis of this uncommon presentation.
  1 2,695 126
ORIGINAL ARTICLES
Radical treatment of locally advanced head and neck cancer with concurrent chemo radiation-cisplatin versus carboplatin: A randomized comparative phase III trial
Shatarupa Dutta, Suman Ghorai, Krishnangshu B Choudhury, Anup Majumder
April-June 2013, 2(2):122-127
DOI:10.4103/2278-0513.113634  
Context: Concurrent chemoradiation with cisplatin is a standard approach for definitive management of locally advanced head and neck squamous cell carcinoma (LAHNSCC). Carboplatin, though a platinum group of drug, is generally well-tolerated compared to cisplatin. Aim: The aim is whether carboplatin can be a substitute of cisplatin with equivalent response and with less toxicity profile. Settings and Design: Single institutional prospective randomized phase III study. Materials and Methods: Between January 2011 and August 2012, 100 patients LAHNSCC with normal comorbidities were included. The patients in Arm A received injection carboplatin (AUC 6) 3 weeks along with external beam radiotherapy (EBRT) dose 66-70 Gy in conventional fractionation and Arm B received injection cisplatin (100 mg/m 2 ) 3 weeks with same EBRT schedule. Detailed clinical examination along with biopsy for residual or recurrent disease, CT scan of head and neck were done to assess the response, toxicities, and disease-free survival (DFS) in follow-up. Statistical Analysis Used: SPSS version 17 used for statistical calculation. For categorical variables, Chi-Square and Fisher Exact tests were used. For continuous variables, independent samples t test were used with 95% CI. Kaplan-Meier survival analysis was used for comparing the DFS. Results: Overall response rate (CR + PR) were 76.9% in Arm A and 63.6% in Arm B (P = 0.06, non-significant). Statistically significant acute skin (P = 0.003), mucosa (P = 0.003), and upper GI (P = <0.0001) toxicities were found more in cisplatin arm compared to carboplatin arm except acute haematological toxicities. Conclusions: It can be concluded that carboplatin is non-inferior in response with statistically significant less toxicities when compared with cisplatin.
  1 2,078 190
Female lung cancer in Marrakech
Mouna Khouchani, Imade Selmaji, Badr Elmorabit, Nabil Ismaili, Abdelhamid Elomrani, Rhizlane Belbaraka, Ali Tahri
April-June 2013, 2(2):128-131
DOI:10.4103/2278-0513.113635  
Background: To evaluate the epidemiological aspect of lung cancer in women in Marrakech city in Morocco. Methods: This is a retrospective study conducted between 2003 and 2009 in the Department of Oncology-Radiotherapy, University Hospital Mohamed VI Marrakech. Results: Twenty nine women with lung cancer were unrolled (9% of all lung cancer). The average age was 55.7 ± 12 years. Only twenty percent of our patients were smokers while 38% reported a greater or lesser exposure to passive smoking. Ninety percent of patients were housewives and 62% were from rural areas and all reported massive exposure to smoke from cooking fuels which was mainly charcoal. Squamous cell carcinoma represents 67% of cases. Tumors were diagnosed at advanced stages II/IV in 81% of cases. Eight patients received neo-adjuvant chemotherapy followed by radio-chemotherapy combination and palliative chemotherapy has been indicated in twelve patients. Nine patients received best supportive care. Average follow-up was of twelve months. Fourteen patients were lost to follow-up. Among fifteen evaluable patients, response was noted in seven patients, stabilization in four patients and progression in four patients. Conclusion: Female lung cancer is a relatively rare condition in Marrakech, Morocco. Although the role of smoking in the pathogenesis of lung cancer is clearly established; there are other risk factors including hormones that make women more susceptible to carcinogens of tobacco. Other geographical and environmental factors could be incriminated including domestic smoke exposure especially in our context.
  1 1,410 80
REVIEW ARTICLES
Update on Hodgkin's lymphoma
Robin Sabharwal, Shamindra Sengupta, Bhudev Sharma, Shivangi Gupta
April-June 2013, 2(2):106-112
DOI:10.4103/2278-0513.113630  
Lymphomas constitute approximately 5% of all malignant neoplasms of the head and neck. They are divided into two major subtypes, Hodgkin's lymphomas (HLs) and non-HLs, depending on the presence or absence of Reed-Sternberg cells (RSCs). HL is a malignant tumor characterized by pleomorphic lymphocytic and histiocytic infiltrate with multinucleated RSCs. HL is regarded as encompassing two clearly defined entities according to the WHO classification: Nodular lymphocyte predominant HL and classical HL. These two entities differ in clinical features and behavior but, more importantly, in the pathological and biological features of their neoplastic and microenvironmental compartments. The etiology of HD remains unknown. Epstein-Barr virus (EBV) plays an important role in the pathogenesis of HL The diagnosis of HL is based on the finding of Reed-Sternberg cells (RSCs) in an appropriate cellular background of reactive lymphocytes and, in some cases fibrosis. The staging system for HL is the Ann Arbor staging system which was developed in 1971. This paper reviews the clinical presentation, classification, various variants and pathogenesis of HL.
  1 3,966 205
CASE REPORTS
Malignancy in pilonidal disease: Uncommon occurrence
Snigdha Goyal, Sunder Goyal, Monika Garg
April-June 2013, 2(2):153-155
DOI:10.4103/2278-0513.113640  
Development of malignancy in pilonidal sinus is a rare complication. The disease occurs most frequently in men. About 69 cases have been reported so far in literature. The lesion is mostly a well-differentiated squamous cell carcinoma. Best treatment is local wide excisions along with a short period of local wound care. After healthy granulation tissue, definitive closure of the defect is done with rotational flaps or skin grafts. Fine needle aspiration cytology is mandatory for palpable inguinal nodes. The prognosis is very poor if inguinal node has metastatic deposits. Radiation therapy may be used as palliative therapy for local bone or soft tissue recurrences. Recently, both topical and systemic chemotherapy have been used without promising results.
  - 5,183 76
Synchronous papillary urothelial carcinoma of urinary bladder and adenocarcinoma of stomach in a middle-aged man: An extremely rare association with therapeutic dilemma
Dodul Mondal, Neeraj Rastogi, Tamojit Chaudhuri, Manoj Jain
April-June 2013, 2(2):156-159
DOI:10.4103/2278-0513.113641  
Synchronous occurrence of urinary bladder carcinoma and gastric carcinoma is very rare. A middle-aged Asian man presented with complaints of hematuria which was diagnosed due to muscle invasive papillary urothelial carcinoma of urinary bladder. Metastatic work-up revealed simultaneous presence of locally advanced gastric adenocarcinoma. He was treated with TURBT for the bladder cancer and was planned for radical gastric resection followed by radiation to urinary bladder and stomach with concurrent chemotherapy. However, due to very advanced nature of the gastric tumor patient was treated only with palliative gastric resection followed by palliative radiation to both urinary bladder and stomach due to his poor performance status. Lack of published English literature and evidence related to such clinical entity made this an extremely rare clinical entity and treatment decision difficult.
  - 3,655 79
Synchronous sporadic medullary carcinoma of the thyroid and small-cell carcinoma of lung: A rare entity
Manigreeva Krishnatreya, Tashnin Rahman, Jagannath Sharma, Amal Kataki
April-June 2013, 2(2):170-172
DOI:10.4103/2278-0513.113645  
Synchronous medullary carcinoma of the thyroid and small-cell carcinoma of the lung is a rare phenomenon and both these tumors are characterized by poor treatment outcome and prognosis. A 45-year-old woman presented with a progressive swelling in front and side of the neck of 3-month duration without any pulmonary symptoms. The tumor of the lung was an incidental finding on routine chest radiological examination. The diagnosis of synchronous primary cancers of the thyroid and the lung were made after cytopathological examination of both the lesions. We report here a case of loco-regional sporadic medullary carcinoma of the thyroid associated with limited stage small-cell carcinoma of the lung and its therapeutic challenges.
  - 1,140 70
LETTER TO THE EDITOR
Palliative care in a rural Indian setup: An oncologist's experience
Vivek Tiwari
April-June 2013, 2(2):173-174
DOI:10.4103/2278-0513.113646  
  - 1,095 79
ORIGINAL ARTICLES
Oral cancer knowledge among Turkish dental patients
Melda Misirlioglu, Rana Nalcaci, Selmi Yilmaz Yardimci, Mehmet Zahit Adisen
April-June 2013, 2(2):149-152
DOI:10.4103/2278-0513.113639  
Aims: To determine the level of oral cancer awareness and knowledge among patients referred to the Department of Oral and Maxillofacial Radiology in Central Anatolia. Settings and Design: The study was conducted with 1,125 patients who applied to the school of dentistry for routine dental examinations. The authors collect information with a 20-item written questionnaire from the participants about oral cancer risk factors, epidemiology, etiology, and signs and symptoms. Statistical Analysis: Descriptive statistics of demographic variables and other data were reported as means and percentages. Statistical analysis was performed by means of SPSS +11.0 statistical package. Results: Overall, only 48.9% of all patients showed awareness of oral cancer, with awareness especially poor among lower socioeconomic groups. Awareness of oral cancer risk factors and signs and symptoms did not vary significantly between men and women (P > 0.5); however, older participants (aged 40-64 years) were more familiar with oral cancer signs than younger participants. More than half of all participants (56.8%) were unaware of the common clinical presentations of oral cancer. Conclusions: The results of this survey showed knowledge regarding oral cancer to be quite low. Thus, educational programs are needed to increase public awareness about oral cancer, and dentists should request patients undergo examinations for oral cancer to ensure early detection.
  - 1,430 123
Nature of axillary drainage fluid after axillary lymph node dissection in breast cancer
Shaji Thomas, Vishal Kumar, Anita Nangia, Ritu Singh, Lalit Aggarwal, Sanjeev Kumar Tudu
April-June 2013, 2(2):113-117
DOI:10.4103/2278-0513.113632  
Introduction: Prolonged postoperative axillary drainage is a common cause of morbidity after axillary lymph node dissection (ALND). There no consensus about the nature of fluid in prolonged axillary drainage. The aim of our prospective observational study was to determine the nature of axillary drainage fluid and to study the change in its composition with prolonged drainage. Materials and Methods: Thirty breast cancer patients scheduled to undergo ALND were evaluated by preoperative hemogram, total protein, serum albumin, serum globulin and A:G (albumin:globulin) ratio, and a complete lipid profile, which was repeated on 5 th postoperative day, along with serum interleukin 1β, interleukin 6, tumor necrosis factor (TNF)-α, and interferon γ. The daily and total axillary drainage was recorded till removal of drain. The axillary fluid was evaluated for total and differential cell count, proteins, triglycerides, and cholesterol on the 3 rd , 5 th , and 7 th postoperative day (POD), and for interleukin 1β, interleukin 6, TNF-α, and interferon γ on 5 th POD. Observations: Axillary fluid leukocyte count increased initially but then decreased; from initial polymorpholeukocytoses, it became predominantly lymphocytes by 7 th day. On the 5 th POD, axillary fluid inflammatory cytokine levels exceeded serum values by several times. Cholesterol and low-density lipoprotein levels in the drain fluid increased initially and then decreased by 7 th day. Total protein content, albumin level, A:G ratio, and high-density lipoprotein levels decreased significantly and continuously. Triglycerides showed progressive increment from the 3 rd to the 7 th day. Conclusions: Axillary drainage fluid is initially an inflammatory exudate which changes to nature of lymph when the drainage is prolonged. It is important to prevent lymph leakage during and after mastectomy and to minimize the intensity and duration of the first phase of wound repair to decrease the morbidity due to prolonged axillary drainage.
  - 3,890 141
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