Evaluation of skull bone viability and effect of early surgical intervention in electrical contact burns using 18 F-Sodium Fluoride PET-CT imaging

OBJECTIVE

Electrical contact burns of the scalp cause serious morbidity and mortality. Early necrotic bone debridement and flap cover are crucial for successful wound closure. 18 F Sodium Fluoride (NaF), with high bone-to-soft tissue activity ratio, is useful for bone viability assessment. This study evaluated the role of 18 F NaF PET-computed tomography (CT) in objectively defining the extent and depth of nonviable calvarial bone, to guide adequate bone debridement.

METHOD

Of 20 patients referred to our institute with electrical contact burns of the scalp during a 2-year period, 15 were enrolled in the study. Two weeks after the initial management, tracer uptake pattern was noted on 18 F NaF PET-CT of the head and exposed bone measured. Surgical bone debridement was based on scan findings, followed by wound closure. All patients underwent clinical evaluation and follow-up scan 3 months after surgery.

RESULTS

Eight patients showed a central photopenic area in the exposed bone (maximum standardized uptake value [SUVmax] of 0.76 ± 0.14 with mean maximum dimensions 4.10 ± 1.76/2.67 ± 1.54 cm). High tracer uptake (SUVmax, 9.66 ± 6.03) was seen peripheral to the exposed bone (mean maximum dimensions, 8.14 ± 3.03/4.75 ± 1.61 cm). Postoperatively, there was no significant change in tracer uptake in the central debrided region or peri-debridement bone area under the flap. Clinically all patients showed a well-healed flap.

CONCLUSION

18 F NaF PET-CT appears useful for objective evaluation of skull bone viability and planning necrotic bone debridement in patients with electrical contact burns. However, additional studies with longer patient follow-up are required to validate these results.

68 Ga-FAPI PET/CT in an Interesting Case of Metastatic Pulmonary Meningioma

ABSTRACT

Meningiomas are one of the major primary CNS tumors. Most meningiomas are benign, but rarely, these metastasize to distant organs, the lungs being the commonest site of metastasis. 18 F-FDG PET/CT has been used to evaluate metastatic pulmonary meningioma. However, 68 Ga-FAPI PET/CT has not yet been evaluated. The present case highlights the 68 Ga-FAPI uptake in metastatic pulmonary meningioma in a postoperated case of left tentorial meningioma presenting with lung masses. Image-guided biopsy from the lung mass was consistent with metastatic meningioma.

Advances in Vibrio-related infection management: an integrated technology approach for aquaculture and human health

Vibrio species pose significant threats worldwide, causing mortalities in aquaculture and infections in humans. Global warming and the emergence of worldwide strains of Vibrio diseases are increasing day by day. Control of Vibrio species requires effective monitoring, diagnosis, and treatment strategies at the global scale. Despite current efforts based on chemical, biological, and mechanical means, Vibrio control management faces limitations due to complicated implementation processes. This review explores the intricacies and challenges of Vibrio-related diseases, including accurate and cost-effective diagnosis and effective control. The global burden due to emerging Vibrio species further complicates management strategies. We propose an innovative integrated technology model that harnesses cutting-edge technologies to address these obstacles. The proposed model incorporates advanced tools, such as biosensing technologies, the Internet of Things (IoT), remote sensing devices, cloud computing, and machine learning. This model offers invaluable insights and supports better decision-making by integrating real-time ecological data and biological phenotype signatures. A major advantage of our approach lies in leveraging cloud-based analytics programs, efficiently extracting meaningful information from vast and complex datasets. Collaborating with data and clinical professionals ensures logical and customized solutions tailored to each unique situation. Aquaculture biotechnology that prioritizes sustainability may have a large impact on human health and the seafood industry. Our review underscores the importance of adopting this model, revolutionizing the prognosis and management of Vibrio-related infections, even under complex circumstances. Furthermore, this model has promising implications for aquaculture and public health, addressing the United Nations Sustainable Development Goals and their development agenda.

Incidentally Detected Gallbladder Carcinoma: Can F-18 FDG PET/CT Aid in Staging and Prognostication?

Purpose

Incidental gallbladder carcinoma (IGBC) is diagnosed in post-cholecystectomy specimens for benign indications, where the role of 2-fluro-2-deoxyglucose positron emission tomography/computed tomography(FDG-PET/CT) is not clearly defined. The present study aimed to assess the benefits of staging and prognosticating with FDG-PET/CT in IGBC.

Materials and Methods

A retrospective observational study from a tertiary-care center from January 2010 to July 2020 was performed. The demographic, clinical, histopathological, and treatment-related histories were collected. FDG-PET/CT-image findings were compared with survival outcomes through telephonic follow-up. The chi-square test was used for comparing frequencies. The univariate and multivariate survival estimates were analyzed using the Kaplan-Meier analysis and the Cox-proportional hazard model, respectively. Log-rank test was used to compare the Kaplan-Meier curves.

Results

The study included 280 postcholecystectomy participants (mean age: 52 ± 11 years; women: 227) of whom 52.1% had open surgery(146/280). Residual disease in the gallbladder fossa (54.8% vs. 36.6%, p = 0.002) and liver infiltration (32.9% vs. 22.4%, p = 0.05) were seen more frequently in open surgery compared to laparoscopic surgery, while anterior abdominal wall deposits were more common in laparoscopy(35.1% vs. 24%,p = 0.041). FDG-PET/CT changed the management in 10% (n = 28) of patients compared to contrast-enhanced CT. The median survival was 14 months (95%CI-10.3-17.7). A higher stage of the disease on the FDG-PET/CT (loco-regional disease-HR 4.86, p = 0.006; metastatic disease-HR 7.53, p < 0.001) and the presence of liver infiltration (HR-1.92, p = 0.003) were independent predictors of poor survival outcomes.

Conclusion

FDG-PET/CT detects residual and metastatic disease in patients with IGBC, enabling the institution of appropriate management and acting as a tool for prognostication of survival.

Efficacy of Yttrium-90 Transarterial Radioembolisation in Advanced Hepatocellular Carcinoma: An Experience With Hybrid Angio-Computed Tomography and Glass Microspheres

Background

Hepatocellular carcinoma is one of the most common malignancies worldwide. Transarterial radioembolisation (TARE) involves selective intra-arterial administration of microspheres loaded with a radioactive compound like Yttrium-90 (Y-90). Conventionally, C-arm-based cone-beam computed tomography has been extensively used during TARE. However, angio-computed tomography (CT) is a relatively new modality which combines the advantages of both fluoroscopy and fCT. There is scarce literature detailing the use of angio-CT in Y90 TARE.

Methods

This was a retrospective study of primary liver cancer cases in which the TARE procedure was done from November 2017 to December 2021. Glass-based Y-90 microspheres were used in all these cases. All the cases were performed in the hybrid angio-CT suite. A single photon emission computed tomography-computed comography (SPECT-CT) done postplanning session determined the lung shunt fraction and confirmed the accurate targeting of the lesion. Postdrug delivery, positron emission tomography-computed tomography (PET-CT) was obtained to confirm the distribution of the Y-90 particles. The technical success, median follow-up, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were recorded.

Results

A total of 56 hepatocellular carcinoma patients underwent TARE during this period, out of which 36 patients (30 males and 6 females) underwent Y90 TARE. The aetiology of cirrhosis included non-alcoholic steatohepatitis (NASH) (11), hepatitis C (HCV) (11), hepatitis B (HBV) (9), metabolic dysfunction and alcohol-associated liver disease (MetALD) (2), alcoholic liver disease (ALD) (1), cryptogenic (1), and autoimmune hepatitis (AIH) (1). The technical success was 100 % and the median follow-up was 7 months (range: 1-32 months). The median OS was 15 months (range 10.73-19.27 months; 95 % CI) and the median local PFS was 4 months (range 3.03-4.97 months; 95 % CI). The ORR (best response, CR + PR) was 58 %. No major complications were seen in this study.

Conclusion

TARE is a viable option for liver cancer in all stages, but more so in the advanced stages. The use of angio-CT in TARE aids in the precise delivery of the particles to the tumour and avoids non-target embolisation.

FDG PET/CT in the Diagnosis and After Sunitinib Follow-up of Synchronous Base of Tongue and Thyroid Metastases From Renal Cell Carcinoma

ABSTRACT

Renal cell carcinoma (RCC) is a leading cause of mortality among genitourinary malignancies with limited therapeutic options. The hematogenous route, lymphatic spread, and direct invasion have been documented in RCC. Usually, metastases are regional lymph nodes, lungs, bone, liver, adrenal glands, contralateral kidney, and brain. Metastases to the rare sites such as skin, breast, head and neck were documented in the literature. In the present case, we describe the synchronous metastases to the base of the tongue and thyroid gland in RCC and the response to sunitinib therapy on 18F-FDG PET/CT.

EBSD investigation of microstructure and microtexture evolution on additively manufactured TiC-Fe based cermets-Influence of multiple laser scanning

Sustainable TiC-Fe-based cermets have been fabricated by adopting an Additive Manufacturing route based on laser powder bed fusion technology (L-PBF). The objective is to produce crack-free cermet components by employing novel multiple laser scanning techniques with variations in laser process parameters. Electron backscatter diffraction analysis (EBSD) was used to study the microstructure and microtexture evolution with variations in laser process parameters. The investigation revealed that adjusting the preheating scan speed (PHS) and melting scan speed (MS) influenced the growth and nucleation of TiC phases. Lowering these speeds resulted in grain coarsening, while higher scan speeds led to grain refinement with larger sub-grain boundaries. Moreover, a high scanning speed increases the degree of dislocation density and internal stress in the fabricated cermet parts. Notably, it is revealed that decreasing the laser scan speed enhanced the proportion of high-angle grain boundaries in the cermet components, signifying an increase in material ductility.

Metabolic tumour volume in Hodgkin lymphoma-A comparison between manual and AI-based analysis

AIM

To compare total metabolic tumour volume (tMTV), calculated using two artificial intelligence (AI)-based tools, with manual segmentation by specialists as the reference.

METHODS

Forty-eight consecutive Hodgkin lymphoma (HL) patients staged with [18F] fluorodeoxyglucose positron emission tomography/computed tomography were included. The median age was 35 years (range: 7-75), 46% female. The tMTV was automatically measured using the AI-based tools positron emission tomography assisted reporting system (PARS) (from Siemens) and RECOMIA (recomia.org) without any manual adjustments. A group of eight nuclear medicine specialists manually segmented lesions for tMTV calculations; each patient was independently segmented by two specialists.

RESULTS

The median of the manual tMTV was 146 cm3 (interquartile range [IQR]: 79-568 cm3) and the median difference between two tMTV values segmented by different specialists for the same patient was 26 cm3 (IQR: 10-86 cm3). In 22 of the 48 patients, the manual tMTV value was closer to the RECOMIA tMTV value than to the manual tMTV value segmented by the second specialist. In 11 of the remaining 26 patients, the difference between the RECOMIA tMTV and the manual tMTV was small (<26 cm3, which was the median difference between two manual tMTV values from the same patient). The corresponding numbers for PARS were 18 and 10 patients, respectively.

CONCLUSION

The results of this study indicate that RECOMIA and Siemens PARS AI tools could be used without any major manual adjustments in 69% (33/48) and 58% (28/48) of HL patients, respectively. This demonstrates the feasibility of using AI tools to support physicians measuring tMTV for assessment of prognosis in clinical practice.

18 F-FDG PET/CT in Lupus Enteritis Presenting With Fever and Abdominal Pain

ABSTRACT

Systemic lupus erythematosus is a systemic autoimmune disease associated with various manifestations. Here, we report a compelling case of a 42-year-old woman who presented with lupus enteritis as a sole manifestation of systemic lupus erythematosus and underwent 18 F-FDG PET/CT. The resected bowel segment revealed vasculitis, and subsequent workup revealed positive antinuclear and anti-double-stranded antibody levels, confirming lupus enteritis, thus highlighting the diagnostic role of 18 F-FDG PET/CT in reaching the final diagnosis.

Unusual Sites of Visceral Spread in Prostate Cancer: A Prostate-Specific Membrane Antigen-Based Theranostic Imaging Series

ABSTRACT

Prostate cancer commonly metastasizes to lymphatic and skeletal systems with lesser frequency to visceral organs; however, uncommon visceral sites have also been found and reported as case reports. We present a series of uncommon metastatic visceral spread in prostate cancer on prostate-specific membrane antigen-based diagnostic and posttherapeutic imaging modalities.

Cryopreservation of bovine semen using extract of Cinnamomum zeylanicum

BACKGROUND

Antioxidants minimise oxidative stress and enhance sperm quality in the process of cryopreservation.

OBJECTIVE

To assess the impact of Cinnamomum zeylanicum extract as an additive during the post-dilution and post-thaw stages of Murrah buffalo semen cryopreservation.

MATERIALS AND METHODS

The semen sample was diluted using Tris-Egg-Yolk-Citric-Acid-Fructose-Glycerol extender and subsequently divided into three groups: Group 1, TEYCAFG without any additives or controls (C); Group 2, TEYCAFG fortified with a 50 ug/mL aqueous extract of cinnamon (T1); and Group 3, TEYCAFG fortified with a 50 ug/mL ethanolic extract of cinnamon (T2). The evaluation included an assessment of progressive motility, live spermatozoa, sperm abnormalities, HOST, CMPT, and enzyme leakage (GOT and GPT) at both the post-dilution and post-thaw stages.

RESULTS

The groups that received cinnamon supplementation demonstrated statistically significant improvements (p<0.05) in various parameters, including an increase in the progressive motility, live spermatozoa, and HOS-positive spermatozoa, as well as greater distance traveled by vanguard spermatozoa compared to the control group. Furthermore, the cinnamon-added groups exhibited a significant decrease (p<0.05) in the percentage of sperm abnormalities and lower enzyme leakage (GOT and GPT) in post-thawed semen.

CONCLUSION

Aqueous extract of C. zeylanicum at a concentration of 50 µg/mL provides superior protection of sperm structures and functions as compared to both the ethanolic extract of C. zeylanicum at the same concentration and the control group. Doi.org/10.54680/fr24310110712.

Reverse engineering protection: A comprehensive survey of reverse vaccinology-based vaccines targeting viral pathogens

Vaccines have significantly reduced the impact of numerous deadly viral infections. However, there is an increasing need to expedite vaccine development in light of the recurrent pandemics and epidemics. Also, identifying vaccines against certain viruses is challenging due to various factors, notably the inability to culture certain viruses in cell cultures and the wide-ranging diversity of MHC profiles in humans. Fortunately, reverse vaccinology (RV) efficiently overcomes these limitations and has simplified the identification of epitopes from antigenic proteins across the entire proteome, streamlining the vaccine development process. Furthermore, it enables the creation of multiepitope vaccines that can effectively account for the variations in MHC profiles within the human population. The RV approach offers numerous advantages in developing precise and effective vaccines against viral pathogens, including extensive proteome coverage, accurate epitope identification, cross-protection capabilities, and MHC compatibility. With the introduction of RV, there is a growing emphasis among researchers on creating multiepitope-based vaccines aiming to stimulate the host's immune responses against multiple serotypes, as opposed to single-component monovalent alternatives. Regardless of how promising the RV-based vaccine candidates may appear, they must undergo experimental validation to probe their protection efficacy for real-world applications. The time, effort, and resources allocated to the laborious epitope identification process can now be redirected toward validating vaccine candidates identified through the RV approach. However, to overcome failures in the RV-based approach, efforts must be made to incorporate immunological principles and consider targeting the epitope regions involved in disease pathogenesis, immune responses, and neutralizing antibody maturation. Integrating multi-omics and incorporating artificial intelligence and machine learning-based tools and techniques in RV would increase the chances of developing an effective vaccine. This review thoroughly explains the RV approach, ideal RV-based vaccine construct components, RV-based vaccines designed to combat viral pathogens, its challenges, and future perspectives.

Convoluted Neural Network for Detection of Clinically Significant Prostate Cancer on 68 Ga PSMA PET/CT Delayed Imaging by Analyzing Radiomic Features

Purpose

To assess the utility of convoluted neural network (CNN) in differentiating clinically significant and insignificant prostate cancer in patients with 68 Ga PSMA PET/CT-targeted prostate biopsy-proven prostate cancer.

Methods

In this retrospective study, 142 patients with clinical suspicion of prostate cancer were evaluated who underwent 68 Ga-PSMA PET/CT imaging followed by 68 Ga-PSMA PET/CT-targeted prostate biopsy from the PSMA-avid prostate lesion. Twenty patients with no PSMA-avid lesions were excluded. Local Image Features Extraction (LifeX) software was used to extract radiomic features (RF) from delayed 68 Ga-PSMA PET/CT images of 122 patients. LifeX failed to extract radiomic features in 24 patients, and the remaining 98 were evaluated. RFs were fed to an in-built CNN of the software for computation and results were achieved. Patients with Gleason Score ≥ 7 on histopathology were labeled clinically significant prostate cancer (csPCa). The diagnostic values of radiomic features were evaluated.

Results

The csPCa was revealed in 69/98 (70.4%) patients, and insignificant PCa was noticed in 29/98 (29.6%) patients. The software extracted 124 RF from the delayed 68 Ga-PSMA PET/CT images. The accuracy of the CNN was 80.7% to differentiate clinically significant and clinically insignificant prostate cancer, with an error percentage (E %) of 19.3%. The sensitivity, specificity, positive predictive, and negative predictive values were 90.3%, 57.7%, 83.6%, and 71.4%, respectively, to detect csPCa.

Conclusion

CNN is a feasible pre-biopsy screening tool for identifying clinically significant prostate cancer and can be used as an adjunct in the initial diagnosis and early treatment planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13139-023-00832-3.

Structural-functional analysis of drug target aspartate semialdehyde dehydrogenase

Aspartate β-semialdehyde dehydrogenase (ASADH) is a key enzyme in the biosynthesis of essential amino acids in microorganisms and some plants. Inhibition of ASADHs can be a potential drug target for developing novel antimicrobial and herbicidal compounds. This review covers up-to-date information about sequence diversity, ligand/inhibitor-bound 3D structures, potential inhibitors, and key pharmacophoric features of ASADH useful in designing novel and target-specific inhibitors of ASADH. Most reported ASADH inhibitors have two highly electronegative functional groups that interact with two key arginyl residues present in the active site of ASADHs. The structural information, active site binding modes, and key interactions between the enzyme and inhibitors serve as the basis for designing new and potent inhibitors against the ASADH family.

Gum acacia based hydrogels and their composite for waste water treatment: A review

The non-toxic nature of natural polysaccharides and their biodegradability makes them the first choice of researchers. Various natural polysaccharides are available nowadays, like cellulose, starch, chitosan, gum acacia, guar gum etc. Among these, gum acacia is a common natural polysaccharide presently used in research and technology. It is highly biodegradable, pH stable and shows appropriate water solubility. It is used in research to synthesize hydrogels and hydrogel nanocomposites for various applications because of its antimicrobial, anti-inflammatory and excellent absorption properties. The major fields of applications include the stabilization of metal nanoparticles in the form of nanocomposites, wound dressing materials, delivery systems of various drugs and pharmaceutical agents, bioengineering, tissue engineering, purification of water, synthesis of antibacterial and antifungal composites for agricultural improvements, and many others. Due to the increasing problem of water pollution, the major focus is on research helping to reduce this problem. Gum acacia-based hydrogel and hydrogel composites were synthesized and tested for pollutant removal efficiency from wastewater by different researchers. The research on gum acacia hydrogel and their hydrogel composite applications for water purification, as well as their synthesis processes and properties, are summarized in this review article.

Unusual Perineal Metastasis in a Case of Prostate Cancer on 68 Ga-PSMA-11 PET/CT

ABSTRACT

Prostate cancer is the fifth leading cause of death in the male population worldwide. 68 Ga-PSMA PET/CT has proved to be an excellent modality with greater accuracy for nodal and bone/visceral metastases staging than bone scintigraphy and CT scan, with high sensitivity and specificity. Common sites of metastasis include bone (84%), lymph nodes (10.6%), liver (10.2%), lung, and pleura (9.1%); however, metastasis to the skin is quite rare (≤0.36%). The present case demonstrates PSMA-avid perineal metastasis in a patient of prostate cancer postchemoradiotherapy on 68 Ga-PSMA PET/CT scan.

18 F-FDG PET/CT in Renal Allograft Tuberculosis Mimicking as Posttransplant Malignancy

ABSTRACT

The most common complications after the renal transplant are infections and malignancies, including posttransplant lymphoproliferative disorders. Tubercular infection in renal allograft recipients is a relatively rare entity. However, nonspecific constitutional symptoms often delay diagnosis, leading to significant morbidity and mortality. We present the 18 F-FDG PET/CT findings in a patient with renal allograft tuberculosis who had clinical and imaging suspicion of posttransplant lymphoproliferative disorder or renal cell carcinoma. Histopathology from the renal lesion revealed tuberculosis.

Nodular type but not vitamin D levels increases the risk of second primary cancers in melanoma patients: An observational study of 663 patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

Nodular Type but Not Vitamin D Levels Increases the Risk of Second Primary Cancers in Melanoma Patients: An Observational Study of 663 Patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

68 Ga-PSMA-11 Uptake in a Large Fibroadenoma in a Male Axillary Accessory Breast

ABSTRACT

Prostate-specific membrane antigen PET imaging has revolutionized the role of prostate cancer diagnosis and management, with very high sensitivity and specificity. To prevent misdiagnosis and for accurate therapy planning, prostate-specific membrane antigen (PSMA) uptake in nonprostatic diseases needs to be recognized correctly. Besides the physiological PSMA expression, 68 Ga-PSMA-11 uptake has been mentioned in multiple oncological and nononcological lesions. The present case report exhibits 68 Ga-PSMA-11 uptake in fibroadenoma in a male accessory breast in the right axillary region.

Periprosthetic metastases in carcinoma of unknown primary: A rare association

ABSTRACT

Septic or aseptic loosening may cause bone loss around artificial prosthesis leading to prosthesis failure. This occurrence due to metastatic infiltration of bone or surrounding soft tissues is rare but has been occasionally reported. We report a case of an elderly lady presenting with swelling and pain at the site of previous hemiarthroplasty performed for traumatic injury. On evaluation, she was found to have a lytic femur lesion with a large soft-tissue component around the prosthetic joint. Biopsy suggested a metastatic carcinoma of renal origin, but screening of kidneys did not reveal any primary lesion. She had additional skeletal metastatic lesions but no other primary site was detected either. She was given palliative radiotherapy and systemic therapy (sunitinib) based on the histologic diagnosis of renal cell origin but did not tolerate it. Thereafter, she is continuing on zoledronate every 4 weeks and best supportive management since 4 months from diagnosis.

LSD1 inhibition suppresses ASCL1 and de-represses YAP1 to drive potent activity against neuroendocrine prostate cancer

Lysine-specific demethylase 1 (LSD1 or KDM1A ) has emerged as a critical mediator of tumor progression in metastatic castration-resistant prostate cancer (mCRPC). Among mCRPC subtypes, neuroendocrine prostate cancer (NEPC) is an exceptionally aggressive variant driven by lineage plasticity, an adaptive resistance mechanism to androgen receptor axis-targeted therapies. Our study shows that LSD1 expression is elevated in NEPC and associated with unfavorable clinical outcomes. Using genetic approaches, we validated the on-target effects of LSD1 inhibition across various models. We investigated the therapeutic potential of bomedemstat, an orally bioavailable, irreversible LSD1 inhibitor with low nanomolar potency. Our findings demonstrate potent antitumor activity against CRPC models, including tumor regressions in NEPC patient-derived xenografts. Mechanistically, our study uncovers that LSD1 inhibition suppresses the neuronal transcriptional program by downregulating ASCL1 through disrupting LSD1:INSM1 interactions and de-repressing YAP1 silencing. Our data support the clinical development of LSD1 inhibitors for treating CRPC - especially the aggressive NE phenotype.

Statement of Significance

Neuroendocrine prostate cancer presents a clinical challenge due to the lack of effective treatments. Our research demonstrates that bomedemstat, a potent and selective LSD1 inhibitor, effectively combats neuroendocrine prostate cancer by downregulating the ASCL1- dependent NE transcriptional program and re-expressing YAP1.

68Ga-DOTA.SA.FAPi as a Versatile Diagnostic Probe for Various Epithelial Malignancies: A Head-to-Head Comparison with 18F-FDG

RATIONALE AND OBJECTIVES

Fibroblast Activation Protein (FAP) expressing cancer-associated fibroblasts has been a major breakthrough causing a paradigm shift in targeted theranostics focusing on the tumor microenvironment. In this study, a squaric acid derivative DOTA.SA.FAPi (SA.FAPi) has been evaluated as a potential diagnostic probe in diverse epithelial cancers and compared to the standard-of-care 18F-FDG.

METHODS

25 patients enrolled in this prospective study underwent 18F-FDG and 68Ga-SA.FAPi PET scans on two different days. For biodistribution, standardized uptake values (SUV) were computed by delineating region-of-interest on various body organs. For comparative analysis in disease identification, lesion tracer uptake was quantified using SUVs corrected for lean body mass (SUL), SUVmax, tumor-to-background ratio (TBR) with liver and blood pool as the reference, total lesion glycolysis (TLG for 18F-FDG) and total lesion FAP expression (TLF for 68Ga-SA.FAPi).

RESULTS

25 patients (mean age: 58 ± 8 years) with four types of cancers including hepatocellular carcinoma (HCC, 56% of cohort), gall bladder carcinoma (GB Ca, 12%), adrenocortical carcinoma (ACC, 16%), and breast carcinoma (breast Ca, 16%) were prospectively evaluated. Physiological tracer uptake of 68Ga-SA.FAPi was noted in the salivary glands, thyroid, liver, pancreas, muscles and kidneys with variable uptake in the lacrimal glands, extra-ocular muscles, oral mucosa and uterus. Lesion-based comparative analysis between both the radiotracers demonstrated complete concordant findings in detection of all primary lesions and distant metastases in liver, bones, adrenals and peritoneum whereas discordant findings were noted in lung nodules (20%) and lymph nodes (13%). In overall analysis, 68Ga-SA.FAPi exhibited significantly higher SUVmax (10.3 vs 8.8, p-0.019), SULpeak (6.8 vs 4.9, p-0.000) and SULavg (5.4 vs 4.1, p-0.019) in comparison to 18F-FDG whereas TBR was comparable for both the tracers [TBRLiver: median 1.9 (IQR: 2.6-1.4) vs 1.8 (2.6-1.1), p-0.275; TBRBloodpool: 2.1 (3.7-1.4) vs 2.0 (2.7-1.4), p-0.207]. In subcategorical analysis, 68Ga-SA.FAPi demonstrated higher SUVmax, SULpeak and SULavg values for primary disease (SUVmax: 14.8 (18.7-9.7) vs (12.9-6.6), p-0.087; SULpeak: 8.2 (11.2-6.8) vs 6.3 (8.5-4.4), p-0.037; SULavg: 6.9 ± 2.5 vs 5.1 ± 2.2, p-0.023] and distant metastases (8.8 vs 7.2, p-0.038); 6.3 (8.8-4.4) vs 3.6 (4.4-2.0), p-0.000; 5.4 vs 3.5, p-0.000] whereas comparable values were noted for both the tracers in nodal metastases [9 (13.5-4.1) vs 8 (12.7-4.7), p-0.726; 4.5 (6.2-1.8) vs 4.3 (5.7-2.2), p-0.727; 4.1 ± 2.3 vs 3.7 ± 1.8, p-0.129]. In primary disease, highest 68Ga-SA.FAPi avidity was noted in ACC followed by GB Ca and HCC. In distant metastases, gall bladder, lung and skeletal lesions demonstrated higher 68Ga-SA.FAPi avidity. Moreover, 68Ga-SA.FAPi identified five additional lung lesions which were missed by 18F-FDG in one case of ACC.

CONCLUSION

68Ga-SA.FAPi emerged as an effective, versatile diagnostic probe for imaging various epithelial malignancies similar to 18F-FDG.

Utilising BC observations to estimate CO contributions from fossil fuel and biomass burning in the Central Himalayan region

The Himalayan region is adversely affected by the increasing anthropogenic emissions from the adjacent Indo-Gangetic plain. However, source apportionment studies for the Himalayan region that are crucial for estimating CO concentration, are grossly insufficient, to say the least. It is in this context that our study reported here assumes significance. This study utilizes five years (2014-2018) of ground-based observations of eBC and multiple linear regression framework (MLR) to estimate CO and segregate its fossil fuel and biomass emission fractions at a high-altitude (1958 m) site in the Central Himalayas. The results show that MERRA2 always underestimates the observed CO; MOPITT has a high monthly difference ranging from -32% to +57% while WRF-Chem simulations underestimate CO from February to June and overestimate in other months. In contrast, CO estimated from MLR replicates diurnal and monthly variations and estimates CO with an r2 > 0.8 for 2014-2017. The CO predicted during 2018 closely follows the observed variations, and its mixing ratios lie within ±17% of the observed CO. The results reveal a unimodal diurnal variation of CO, COff (ff: fossil fuel) and CObb (bb: biomass burning) governed by the boundary layer evolution and upslope winds. COff has a higher diurnal amplitude (39.1-67.8 ppb) than CObb (5.7-33.5 ppb). Overall, COff is the major contributor (27%) in CO after its background fraction (58%). CObb fraction reaches a maximum (28%) during spring, a period of increased agricultural and forest fires in Northern India. In comparison, WRF-Chem tracer runs underestimate CObb (-38% to -98%) while they overestimate the anthropogenic CO during monsoon. This study thus attempts to address the lack of continuous CO monitoring and the need to segregate its fossil fuel and biomass sources, specifically over the Central Himalayas, by employing a methodology that utilizes the existing network of eBC observations.

Tubarial salivary glands on PSMA ligands based PET imaging and post 177Lu PSMA therapy scan: reiterating its importance

68Ga-PSMA PET/CT has been routinely utilized in patients with intermediate to high-risk category prostate carcinoma for staging, biochemical recurrence and before planning the PSMA radioligand therapy (RLT). 177Lu-PSMA RLT has also been approved by FDA as a novel treatment modality in metastatic carcinoma prostate patients who have failed to other lines of treatment. The non-target organs like salivary and lacrimal glands have shown to have high physiological PSMA uptake on PSMA PET/CT. Recently, strong uptake of PSMA ligand has also been noted in the dorsal wall of the nasopharynx in the region of torus tubarius on PSMA PET/CT, which has led to the identification of new pair of salivary gland structures called "tubarial salivary glands". The clinical significance of these distinct anatomical structures lies in the fact these structures might be involved in a variety of immune related, inflammatory disorders, malignancies and could be a probable organ at risk during radiotherapy in case of head and neck malignancies, causing adverse effects to the patient.

Potential role of 68Ga-PSMA PET/CT in metastatic renal cell cancer: A prospective study

PURPOSE

Prostate-specific membrane antigen (PSMA), in addition to its utility in prostate cancer, is also an angiogenic imaging marker for hypervascular tumors like renal cell carcinoma (RCC). Our study aims to assess the potential role of 68Ga-PSMA-11 positron emission tomography (PET)/CT in metastatic RCC and compare it with contrast-enhanced computed tomography (CECT).

METHODS

Biopsy-proven RCC patients with known or suspected distant metastases who underwent 68Ga-PSMA-11 PET/CT for staging/restaging were prospectively recruited. Those patients who had undergone 18F-FDG PET/CT within six weeks of 68Ga-PSMA PET/CT were also included retrospectively for comparative analysis. A patient-based and lesion-based analysis was done to compare the lesion detection rates of CECT, 68Ga-PSMA-11 PET and 18F-FDG PET. PET-based quantitative parameters were also compared between both the PET modalities. Impact of baseline parameters on survival was assessed using Cox regression analysis. A p-value of < 0.05 was considered significant.

RESULTS

Thirty-seven patients with median age 60 years ± 13 years (range = 26-76 years) were included in the study. Twenty-seven patients had clear cell (cc) RCC, six had papillary RCC (pRCC), and one each had an eosinophilic variant of ccRCC, collecting duct RCC, translocation RCC and poorly differentiated RCC. 68Ga-PSMA-11 PET performed better in detecting marrow and equivocal bone lesions and worse in detecting liver lesions compared to CECT. 68Ga-PSMA-11 PET-based angiogenic tumor burden estimation using Total Lesion-PSMA (TL-PSMA) and PSMA-Total volume (PSMA-TV) had a prognostic impact on the survival of patients. 68Ga-PSMA-11 PET also detected more lesions and showed significantly higher SUVmax than 18F-FDG PET.

CONCLUSION

68Ga-PSMA-11 PET/CT performs better than CECT and 18F-FDG PET/CT in metastatic evaluation and has prognostic value in the management of clear cell RCC.

Incidental Detection of 68 Ga-DOTA-RGD-2 Uptake in Uterine Fibroid

ABSTRACT

Uterine fibroids are benign tumors originating from the smooth muscle cells of the myometrium seen in approximately 20%-50% of women of reproductive age. The Arg-Gly-Asp (RGD) binds to αvβ3 integrin expressed on the surface of angiogenic blood vessels or tumor cells. 18 F-FDG PET/CT has been used to evaluate uterine fibroids, with moderate 18 F-FDG uptake. However, angiogenesis imaging in uterine fibroids has not been evaluated. The present case presents a rare finding of RGD uptake in the uterine fibroid on 68 Ga-DOTA-RGD-2 PET/CT in a patient who underwent angiogenesis imaging for left ankle joint pain and swelling.

An advanced deep learning method to detect and classify diabetic retinopathy based on color fundus images

BACKGROUND

In this article, we present a computerized system for the analysis and assessment of diabetic retinopathy (DR) based on retinal fundus photographs. DR is a chronic ophthalmic disease and a major reason for blindness in people with diabetes. Consistent examination and prompt diagnosis are the vital approaches to control DR.

METHODS

With the aim of enhancing the reliability of DR diagnosis, we utilized the deep learning model called You Only Look Once V3 (YOLO V3) to recognize and classify DR from retinal images. The DR was classified into five major stages: normal, mild, moderate, severe, and proliferative. We evaluated the performance of the YOLO V3 algorithm based on color fundus images.

RESULTS

We have achieved high precision and sensitivity on the train and test data for the DR classification and mean average precision (mAP) is calculated on DR lesion detection.

CONCLUSIONS

The results indicate that the suggested model distinguishes all phases of DR and performs better than existing models in terms of accuracy and implementation time.

Recurrent Mutations in Refractory/Relapsed Diffuse Large B-Cell Lymphoma by Targeted Gene Sequencing

INTRODUCTION

Whole-genome sequencing of diffuse large B-cell lymphoma (DLBCL) has identified recurrent mutations involved in pathogenesis and potentially affecting response to therapy. In this pilot study, a targeted gene panel was created to identify mutations associated with relapse/refractoriness.

MATERIAL AND METHODS

A 14-gene targeted panel was designed to sequence thirteen patients who were in remission and 8 cases that had relapsed/refractory to treatment. A paired diagnostic biopsy and a relapse biopsy were sequenced to find genes repeatedly altered in relapse.

RESULTS

A total of 751 nonsynonymous and truncating mutations were identified. Truncated mutations in NOTCH1, TNFAIP3, and CD58 were associated with poor treatment outcomes. In cases that did not respond to treatment, a high number of mutations were found in the EZH2 gene, followed by the DNA-binding domain of TP53 and MYD88. Termination mutations in the intracellular domain of NOTCH were found in 75% of non-responsive cases. Co-occurrence of loss of function mutations of TNFAIP3 and missense mutations in MYD88 was associated with a non-responsive cohort.

DISCUSSION

The study highlights mutations associated with chemotherapeutic response in DLBCL with implications for initial diagnostic biopsy response prediction.

A Century of Laffer-Ascher Syndrome

Laffer-Ascher syndrome is characterized by double lips, blepharochalasis, and nongoiter thyroid enlargement. The syndrome was first described in 1923 and several case reports have been published thereafter. We illustrate the syndrome through a case of a 46-year-old woman who presented with both upper and lower double lips and blepharochalasis, and review the literature published. Thyroid involvement is the most inconsistent feature of the syndrome complex described in reported cases.

The Role of Genetic Analysis in Demystifying the Diagnosis in a Middle-Aged Male Presenting With Proximal Muscle Weakness and Sclerotic-Lytic Skeletal Lesions

Paget's disease of bone (PDB) usually presents with bone pain and deformities. Herein, we describe a case of PDB who presented with gradually progressive quadriparesis. A man in his forties presented with gradually progressive proximal muscle weakness involving all four limbs. The patient had an elevated serum alkaline phosphatase level and osteosclerosis at various skeletal sites in a radiological skeletal survey. 18F-fluorodeoxyglucose (FDG) PET-CT showed FDG-avid sclerotic-lytic lesions at multiple skeletal sites. Histopathology evaluation of bone and muscle biopsy specimens revealed PDB and inclusion body myopathy (IBM) with neurogenic atrophy, respectively. A diagnosis of IBM associated with PDB without frontotemporal dementia (IBMPFD) was suspected and confirmed by exome sequencing, which revealed a heterozygous mutation in the VCP gene. The bone disease responded to zoledronate administration. A high index of suspicion for IBMPFD should be kept in mind in any patient with PDB presenting with proximal muscle weakness.

Evaluation of the safety, immunogenicity and efficacy of a new live-attenuated lumpy skin disease vaccine in India

Lumpy skin disease (LSD) was reported for the first time in India in 2019 and since then, it has become endemic. Since a homologous (LSD-virus based) vaccine was not available in the country, goatpox virus (GPV)-based heterologous vaccine was authorized for mass immunization to induce protection against LSD in cattle. This study describes the evaluation of safety, immunogenicity and efficacy of a new live-attenuated LSD vaccine developed by using an Indian field strain, isolated in 2019 from cattle. The virus was attenuated by continuous passage (P = 50) in Vero cells. The vaccine (50^th LSDV passage in Vero cells, named as Lumpi-ProVac^Ind) did not induce any local or systemic reaction upon its experimental inoculation in calves (n = 10). At day 30 post-vaccination (pv), the vaccinated animals were shown to develop antibody- and cell-mediated immune responses and exhibited complete protection upon virulent LSDV challenge. A minimum Neethling response (0.018% animals; 5 out of 26,940 animals) of the vaccine was observed in the field trials conducted in 26,940 animals. There was no significant reduction in the milk yield in lactating animals (n = 10108), besides there was no abortion or any other reproductive disorder in the pregnant animals (n = 2889). Sero-conversion was observed in 85.18% animals in the field by day 30 pv.

Pharmacoinformatic approach to identify potential phytochemicals against SARS-CoV-2 spike receptor-binding domain in native and variants of concern

Severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) pathogenesis is initiated by the binding of SARS-CoV-2 spike (S) protein with the angiotensin-converting enzyme 2 receptor (ACE2R) on the host cell surface. The receptor-binding domain (RBD) of the S protein mediates the binding and is more prone to mutations resulting in the generation of different variants. Recently, molecules with the potential to inhibit the interaction of S protein with ACE2R have been of interest due to their therapeutic value. In this context, the present work was performed to identify potential RBD binders from the Indian medicinal plant's phytochemical database through virtual screening, molecular docking, and molecular dynamic simulation. Briefly, 1578 compounds filtered from 9596 phytochemicals were chosen for screening against the RBD of the native SARS-CoV-2 S protein. Based on the binding energy, the top 30 compounds were selected and re-docked individually against the native and five variants of concern (VOCs: alpha, beta, gamma, delta, and omicron) of SARS-CoV-2. Four phytochemicals, namely withanolide F, serotobenine, orobanchol, and gibberellin A51, were found to be potential RBD binders in native and all SARS-CoV-2 VOCs. Among the four, withanolide F exhibited lower binding energy (- 10.84 to - 8.56 kcal/mol) and better ligand efficiency (- 0.3 to - 0.25) against all forms of RBD and hence was subjected to a 100 ns MD simulation which confirmed its stringent binding to the RBDs in native and VOCs. The study prioritizes withanolide F as a prospective COVID-19 (Coronavirus disease) therapeutic agent based on the observations. It warrants deeper investigations into the four promising leads for understanding their precise therapeutic value.

Accuracy of combined multi-parametric MRI and PSMA PET-CT in diagnosing localized prostate cancer: newer horizons for a biopsy-free pathway

INTRODUCTION

Prostate-specific antigen (PSA) is a reliable biomarker for identification of prostate cancer, although a biopsy is still the gold standard for detecting prostate cancer. Similar to higher PIRADS lesions on MRI, the maximal standard uptake value (SUV max) on PSMA PET is linked to a higher likelihood of prostate cancer. Can an mpMRI in conjunction with PSMA PET Scan accurately predict prostate cancer and further trigger omission of biopsy similar to other solid organ urological malignancies?

METHODS

Ga-68 PSMA PET and mpMRI were performed for each patient who was a part of this retrospective study. The PET-positive lesion's maximum standardized uptake value (SUVmax) was recorded. Prostate biopsies were performed on patients who had PSMA PET avid lesions and a PIRADS score of 4 or 5. Robot-assisted radical prostatectomy (RARP) was afterward performed on patients who had cancer on their prostate biopsy. The prostatectomy specimen's histopathological information was recorded. Cutoff values and correlations between the variables were determined using the ROC curves and Pearson's correlation test.

RESULT

On the basis of suspicious DRE findings or elevated PSA, 70 men underwent mpMRI and PET scans. PIRADS 4 patients had a median (IQR) SUVmax of 8.75 (11.95); whereas, PIRADS 5 patients had an SUVmax of 24.5 (22). The mean SUVmax for patients whose biopsies revealed no cancer was 6.25 ± 1.41. With an AUC of 0.876 on the ROC curve, it was found that there was a significant positive correlation between the results of the mpMRI and PET scans and those of the histopathological investigation. A SUVmax ≥ 8.25 on PSMA PET for a PIRADS 4/5 lesion on mpMRI will aid in correctly predicting malignancy, with a sensitivity of 82.8% and specificity of 100%.

CONCLUSION

The findings of this study were positive and indicated that patients with a high suspicion of prostate cancer on mpMRI and PSMA PET (PIRADS ≥ 4 and SUVmax ≥ 8.25). This study substantiates the fact that a combination of mpMRI and PSMA PET can accurately predict localized prostate cancer.

IMPLICATION OF THREAT FACTORS AND PREEXISTING DISORDERS IN DIFFERENT ISCHEMIC STROKE SUBGROUPS IN ELDERLY PEOPLE: A SYSTEMATIC STUDY

Ischemic stroke is a major health issue, especially for the older population and it may have severe effects. Stroke diagnosis and treatment have advanced over the last 20 years, which has resulted in considerable reductions in death, long-term impairment, and the need for institutional care. Younger age groups have seen the majority of trials for acute, interventional, and preventive therapy. The purpose of this research was to identify distinct subgroups of older people who had suffered an ischemic stroke and examine the role that risk factors and previous illnesses played in their development. Ischemic stroke risk factors varied by age, gender and exhibited their own unique features. Smoking, cholesterol, and psychological/emotional stress were shown to have the greatest prevalence (p<0.06) among stroke patients aged 45-60. Smoking is associated with a significant (p<0.07) decline in health in elderly people. Our results imply that there are significant patterns of risk factors and preexisting illnesses among the various subgroups of older people who have had an ischemic stroke. Atherosclerotic (large-artery) and cardio embolic (small-artery) ischemic strokes were shown to be the most prevalent among the elderly. Strong associations were found between these subtypes and other risk factors, including higher cholesterol, diabetes, high blood pressure, and atrial fibrillation. This research emphasizes the need for individualized preventative methods and therapeutic therapy, as well as the need to recognize the variability of ischemic stroke in the elderly.

In-vivo lymphoscintigraphy of sinonasal tumors identifies retropharyngeal node and level I as predominant sentinel nodes

OBJECTIVE

To evaluate by in- vivo lymphoscintigraphy and SPECT-CT imaging, the lymphatic drainage patterns of para-nasal sinus(PNS) tumors. To confirm or refute the belief of the retropharyngeal lymph node (RPLN) being the significant draining lymph node for such tumors.

METHODS

Prospective cohort study conducted on previously untreated PNS tumors with no clinico-radiological evidence of lymph node metastasis. Lymphoscintigraphy undertaken by nasal endoscopic assisted peritumoral injection of 99mTc Sulfur colloid. Injections were classified as anterior or posterior as per a vertical line along the maxillary sinus ostium.

RESULTS

17 patients were included. Lymphoscintigraphy successfully identified 17 sentinel nodes in 15 patients and was unsuccessful (lymphoscintigraphy failure) in 2 patients. Predominant sites of sentinel lymphatic drainage were noted to be the RPLN (n = 8; 47%), and Level I (n = 7; 42%). Occasional drainage was identified at the peri-parotid node(n = 1) and at Level II (n = 1). Contralateral drainage was noted in 2 patients (level I-1 and RPLN-1). Anterior injections drained predominantly to Level I (6/8) and RPLN (2/8), while posterior injections drained predominantly to the RPLN ( 6/7). The relative risk of RPLN being identified as the sentinel node was significantly higher for posteriorly placed injections than for anteriorly placed injections (RR- 3.43; 95% CI-1.0-11.8, p = 0.05).

CONCLUSION

The RPLN is noted as a frequent draining node for sino-nasal tumours and merits routine attention in all sino-nasal tumors. The radio-colloid SPECT-CT technique described here offers an excellent in-vivo technique to further explore and validate the lymphatic drainage pathways of these tumours.

Clinical Relevance of Sternal Foramina: A Morphometric Study

Objectives

The present study aimed at determining the incidence of sternal foramina in adult dry bones of North Indian descent. We also aimed to determine the number, precise location of the sternal foramina with a standard reference point which might have considerable importance with regard to procedures involving sternal puncture.

Methods

This cross sectional descriptive study was conducted on 72 dry adult human sternums. Various measurements in relation to the sternal foramina were taken with a non-stretchable measuring tape and digital vernier calliper and expressed as: [A]-total sternal length, [B]-distance between the jugular notches to the foramen, [C]-distance between the angle of Louis to the foramen and [D]-distance of the foramen from the mid sternal plane. Statistical analysis was performed with Microsoft Excel version 2019. A p-value of <0.05 was considered significant.

Results

We found 6.94% (5 out of 72 sternums) incidence of sternal foramina which corroborates well with the existing literature. Mean sternal length was 127.7 ± 09 mm. The mean distance of the foramina from suprasternal notch, sternal angle and from the median plane were 118.12 ± 0.3 mm, 116.7 mm and 2.4 mm respectively. Incidence of sternal foramina was almost similar to previously reported studies.

Conclusions

The precise knowledge about the expected location of sternal foramina is imperative to avoid intra-thoracic visceral injury during commonly performed acupuncture needle insertion and while doing bone marrow aspiration for diagnostic evaluation.

Collision in double-image encryption scheme based on spatial encoding and phase-truncation Fourier transforms

In this paper, the security strength of a double-image cryptosystem using spatial encoding and phase-truncation Fourier transforms (PTFTs) is evaluated. Unlike the conventional PTFT-based cryptosystem, where two random phase masks (RPMs) are used as public keys to provide enough phase constrains in the estimation, in the improved cryptosystem, the RPM generated by a random amplitude mask (RAM) is treated as an unknown parameter. Due to this fixed RAM, the number of constraints in the estimation decreases to achieve high robustness against potential iterative attacks. Moreover, instead of two phase-only masks (POMs), here the two POMs and the RAM are utilized as the private keys in the improved cryptosystem; thus, the key space of the double-image cryptosystem has been enlarged. However, we noticed that the RAM used to encode plaintexts spatially and to generate the phase encryption key is independent of the plaintexts. This could be recovered by a known pair of plaintexts and the ciphertext. Once the information of the RAM is retrieved, the phase key RPM can also be produced making the cryptosystem vulnerable. Based on this finding, new hybrid algorithms, including a known-plaintext attack and a known key attack are proposed to crack the enhanced PTFT-based cryptosystem. The information of the plaintexts can be retrieved from one POM using the proposed algorithms without any knowledge of another POM and the corresponding ciphertext. Numerical simulations have been carried out to validate the information disclosure problem still exists in the double-image cryptosystem based on spatial encoding and PTFTs.

Precise Measurement of the D_{s}^{+} Lifetime at Belle II

We measure the lifetime of the D_{s}^{+} meson using a data sample of 207  fb^{-1} collected by the Belle II experiment running at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The lifetime is determined by fitting the decay-time distribution of a sample of 116×10^{3} D_{s}^{+}→ϕπ^{+} decays. Our result is τ_{D_{s}^{+}}=(499.5±1.7±0.9)  fs, where the first uncertainty is statistical and the second is systematic. This result is significantly more precise than previous measurements.

Clinical and Radiological Parameters to Discriminate Tuberculous Peritonitis and Peritoneal Carcinomatosis

It is challenging to differentiate between tuberculous peritonitis and peritoneal carcinomatosis due to their insidious nature and intersecting symptoms. Computed tomography (CT) is the modality of choice in evaluating diffuse peritoneal disease. We conducted an ambispective analysis of patients suspected as having tuberculous peritonitis or peritoneal tuberculosis between Jan 2020 to Dec 2021. The study aimed to identify the clinical and radiological features differentiating the two entities. We included 44 cases of tuberculous peritonitis and 45 cases of peritoneal carcinomatosis, with a median age of 31.5 (23.5-40) and 52 (46-61) years, respectively (p ≤ 0.001). Fever, past history of tuberculosis, and loss of weight were significantly associated with tuberculous peritonitis (p ≤ 0.001, p = 0.038 and p = 0.001). Pain in the abdomen and history of malignancy were significantly associated with peritoneal carcinomatosis (p = 0.038 and p ≤ 0.001). Ascites was the most common radiological finding. Loculated ascites, splenomegaly and conglomeration of lymph nodes predicted tuberculous peritonitis significantly (p ≤ 0.001, p = 0.010, p = 0.038). Focal liver lesion(s) and nodular omental involvement were significantly associated with peritoneal carcinomatosis (p = 0.011, p = 0.029). The use of clinical features in conjunction with radiological findings provide better diagnostic yields because of overlapping imaging findings.

Disseminated Nasal subtype Extranodal NK/T-cell lymphoma and its diagnostic difficulties in antemortem biopsies

Extranodal NK/T- cell lymphoma (ENKTCL) is an aggressive lymphoma driven by Epstein-Barr virus (EBV) infection in genetically susceptible individuals. It was historically called a lethal midline granuloma. Due to the angio-destructive nature of ENKTCL, lymphoma cells are often accompanied and masked by necrosis and dense inflammation in the biopsy. Further, the biopsy may show vasculitis, which can mimic granulomatosis with polyangiitis. Due to these masquerades, ENKTCL is often misdiagnosed in the biopsy. Several biopsies may be required to establish the diagnosis. We describe the clinical course and autopsy findings of a young female who presented with a hard-palate ulcer. Antemortem biopsies failed to establish the diagnosis. The autopsy revealed an advanced nasal subtype of Extranodal NK/T-cell lymphoma with dissemination to the kidneys, adrenals, liver, spleen, and small intestine.

The Landscape of Genetic Alterations Associated with Metachronous Metastasis in Patients with Pancreatic Ductal Adenocarcinoma and Its Prognostic Significance

PURPOSE/OBJECTIVE(S)

Metachronous metastasis is one of the major pathologic processes which significantly increases the mortality of patients with pancreatic ductal adenocarcinoma (PDA) who completed initial curative treatment. Genetic signatures that drive the metachronous mutations are not well investigated. In this study, we aimed to identify the landscape of genetic alterations associated with metachronous metastasis in patients with PDA and its prognostic significance.

MATERIALS/METHODS

We retrospectively identified patients with histologically confirmed PDA who underwent next-generation sequencing using a panel of 324 pre-specified genes. The landscape of somatic mutations was stratified by metastasis types [no metastasis (nMet) vs. de novo metastasis (dMet) vs. metachronous metastasis (mMet)]. Outcomes of interest included overall survival (OS), local recurrence (LR) following radiotherapy, and association of CA 19-9 level with metastasis types. The OS was calculated using the Kaplan-Meier estimates and log-rank test, and LR was measured using cumulative incidence. A multivariate cox-regression analysis was performed to identify prognostic factors. Pathway analysis of mMet exclusive genes was performed using DAVID (Database for Annotation, Visualization, and Integrated Discovery).

RESULTS

A total of 328 patients with PDA were included. Among them, 56 (17%), 145 (44%), and 127 (39%) patients had nMet, dMet, and mMet, respectively. The median follow up was 21.6 months (range 0.7 -136 months). The median age at the time of diagnosis was 65.5 years (range 26.77 -87.31 years). ANOVA test showed that CA 19-9 level was associated with metastasis types (p = 0.034). The median OS was 48.4 (95% CI 28.3-NA), 27.4 (95% CI 23.3-33.9), and 15 (95% CI 13.9-17.8) months for patients with nMet, mMet, and dMet, respectively (p<0.0001). The multivariate analysis (MVA) revealed that KRAS mutation (HR 2.31; 95% CI 1.37-3.9; p = 0.001), mMet (HR 0.45; 95% CI 0.34-0.61; p<0.0001), nMet (HR 0.27; 95% CI 0.16-0.45; p<0.0001), age (HR 1.01; 95% CI 1-1.02; p = 0.03), and male gender (HR 1.5; 95% CI 1.15-2.01; p = 0.002) were associated with OS. Mutations in other PDA driver genes (TP53, SAMD4, CDKN2A) were not associated with OS (p>0.05). The LR rate at 12 months post-radiotherapy was 28% and 27% for nMet and mMet, respectively (p = 0.5). Heatmap analysis identified 31 genes that were exclusively mutated in patients with mMet. These genes were enriched in pathways of transcription regulation by RNA polymerase II promoter binding, a negative regulator of apoptosis, and telomerase maintenance.

CONCLUSION

This study identified metachronous metastasis-associated genetic alterations and molecular pathways. Future prospective studies incorporating whole exome sequencing are warranted to validate these findings.

Early Bone Mineral Density Changes and Endocrinal Dysfunction in Childhood Brain Tumor Patients: A Prospective Study

PURPOSE/OBJECTIVE(S)

Reduced bone mineral density (BMD) and hormonal dysfunction are considered as a late effect of cranial radiation (RT). Only few studies have reported the occurrence of these problems soon after the diagnosis of brain tumor or RT initiation, emphasizing that these are not necessarily the late effects of RT. Thus, we conducted the study to analyze the incidence of low BMD and hormonal dysfunction prior to or within 6 months of RT (early change) in children with brain tumors.

MATERIALS/METHODS

The study was conducted as a part of intramural funding program at a tertiary care center in India. Childhood and adolescent brain tumor patients were advised for dual energy X-ray absorptiometry scan (DXA) and hormonal evaluation prior to RT. In some patients, first DXA was done within 6 months of RT due to logistics. To see the effect of radiation, we have planned to repeat hormonal evaluation after 6 and 12 months and DXA after 12 months of RT.

RESULTS

Twenty-five patients were analyzed. Median age at diagnosis was 11 years with a male to female ratio of 5.2:1. Medulloblastoma was the commonest diagnosis (n = 12), followed by glioma (n = 8), pineal tumors (n = 3) and ependymoma (n = 2). Nineteen and six patients underwent DXA before RT and within 6 months of RT respectively. For BMD assessment, Z score was calculated at hip and lumbar spine. BMD was defined as low (Z score = -1 to-1.99), very low (Z score = -2 to -2.5) and secondary osteoporosis (Z score ≤ -2.5). Median Z score at femur neck and spine was -2 and -1.9 respectively. Overall; 6, 3 and 9 patients had normal, low and very low BMD respectively. Seven patients had secondary osteoporosis (Table 1). Two patients with secondary osteoporosis had low vitamin D levels. None of the patient had compression fracture. On statistical analysis, no correlation was found between BMD changes and age, sex and site of the tumor. Pre RT endocrinal assessment (N = 25) was done by tanner staging and serum hormonal levels (GH, T3/T4/TSH, ACTH, cortisol and prolactin). Gonadal hormonal assessment was done in children with early or delayed puberty. Three patients were found to have endocrinal abnormality before RT (precautious puberty, central hypothyroidism and low sex hormones in 1 patient each). Follow up DXA and hormonal evaluation are awaited to see the effect of RT.

CONCLUSION

The index study is one of the very few studies evaluating the early changes in BMD and hormonal dysfunction soon after brain tumor diagnosis or within 6 months of RT. We observed that a significant proportion of children had reduced BMD and hormonal dysfunction before RT, highlighting the importance of early assessment and referral to the specialist for better quality of life. Table 1: BMD and endocrinal dysfunction before or within 6 months of RT.

Radiation Exposure to the Personnel Performing Myocardial Blood Flow Quantification Study Using 13N-ammonia Positron Emission Tomography/Computed Tomography

Purpose

The present study aimed to evaluate radiation exposure to staff performing coronary flow reserve (CFR) measurement using 13N-ammonia.

Materials and Methods

The radiation exposure rate during the administration of 13N-ammonia for the rest and stress part of the study was noted using an ionization chamber-based calibrated survey monitor. The radiation exposure to persons involved in dispensing radioactivity (D1), administering radioactivity (D2) and monitoring the patient during pharmacological stress (D3) were measured using an energy compensated Si-diode personal pocket dosimeter.

Results

The average dose received by individuals with dosimeters D1, D2, and D3 was 1.28 ± 0.79 µSv, 1.56 ± 0.51 µSv, and 0.88 ± 0.97 µSv per injection, respectively, during the rest of study and 1.56 ± 0.96 µSv, 2.64 ± 1.22 µSv, and 2.2 ± 1.7 µSv per injection, respectively, during stress study. The average exposure rate during the administration of 13N-ammonia at 0.5 m and 1.5 m from the injection site was found to be 259 µSv/h and 53.4 µSv/h, respectively, during the rest study and 301 µSv/h and 67.25 µSv/h, respectively, during stress study.

Conclusion

The exposure to the staff performing CFR study with 13N-ammonia was well within prescribed limits by the International Commission on Radiological Protection 103. The CFR measurement with 13N-ammonia positron emission tomography/computed tomography can be included in routine workups of cardiac patients without the fear of radiation exposure.

Comprehensive Genomic Analysis Stratified by KRAS Status in Patients with Pancreatic Adenocarcinoma and Its Prognostic Significance

PURPOSE/OBJECTIVE(S)

KRAS mutations (MUT) are one of the major drivers in pancreatic ductal adenocarcinoma (PDA) with over 90% of patients having alterations. However, the genetic landscape of PDA based on KRAS status is not well studied. The aim of this study is to investigate genomic alterations based on KRAS status and to identify driver mutations in patients with KRAS wild type (WT).

MATERIALS/METHODS

Next-generation sequencing with 324 pre-specified genes was performed on patients with histologically confirmed PDA. The landscape of somatic mutations was stratified by KRAS status. Outcomes of interest included overall survival (OS), local failure (LF) following radiotherapy, time to metastasis, and CA 19-9 level. All outcomes were stratified by KRAS status. Genetic alterations exclusive to patients with KRAS WT were analyzed. OS was calculated using the Kaplan-Meier estimates and log-rank test, and LF was measured using cumulative incidence. A multivariate cox-regression analysis (MVA) was performed to identify prognostic factors for survival. Gene ontology analysis of KRAS WT exclusive genes was performed via DAVID (Database for Annotation, Visualization, and Integrated Discovery).

RESULTS

A total of 272 patients with metastatic PDA were included. The median age at diagnosis was 65.4 (range, 26.77-83.21) years. The median follow-up was 15.7 (0.06-136.7) months. 91% percent (n = 248) of patients were found to be KRAS MUT. The chi-square test showed that the primary tumor site (p = 0.027) and perineural invasion (p = 0.006) were associated with KRAS status. The median CA 19-9 was 143.6 (15.5-27996) U/ml and 341.15 (0-100000) U/ml for KRAS WT and KRAS MUT, respectively (p = 0.23). The median OS for KRAS WT and MUT was 31.4 (95% CI 25.1-NA) and 13.3 (95% CI 11.3-14.5) months, respectively (p = 0.0008). In patients with metachronous recurrence, the median time to metastasis was 22.4 (1.37-52.97) months and 12.8 (1.8-84.97) months for KRAS WT and KRAS MUT, respectively (p = 0.057). KRAS MUT types including G12 and Q21 were not associated with OS (p = 0.58). On MVA, including KRAS status, age, sex, and metastatic types (de novo vs. metachronous), only KRAS mutation was associated with worse OS [HR 2.64; 95% CI 1.53 to 4.56; p = 0.0004]. In patients treated with radiation, the LF rate at 12 months was 12.5% in patients with KRAS WT and 33.8% in KRAS MUT (p = 0.13). Heatmap analysis identified that RAD50, ALK, BCORL1, BRAF, CDC73, FAM123B, NF2, ERBB4, and ERCC4 were exclusively mutated in patients with KRAS WT. These genes were enriched in pathways associated with tyrosine kinase catalytic domain activity, ubiquitination, and nuclear localization signal.

CONCLUSION

This study identified driver mutations in patients with KRAS WT. KRAS status was associated with pathologic features and disease prognosis after treatment. Further study leveraging more powered cohorts is warranted.

Patient-Reported Outcomes Evaluating the Impact of Hypo-Fractionated Palliative Quadshot Radiotherapy and Concurrent CDDP Treatment on Health-Related Quality of Life in Patients with Locally Advanced Squamous Cell Carcinoma of the Head and Neck

PURPOSE/OBJECTIVE(S)

In locally advanced squamous cell carcinoma of the head and neck (LAHNSCC), the main goal of treatment remains survival while improving quality of life (QOL). In recent decades, there has been a paradigm shift in the measurement of clinical outcomes in patients diagnosed with cancer, focusing on the patient perspective by incorporating patient-reported outcomes (PROs). The primary objective of this study was to evaluate the improvement in quality of life with the use of cyclic hypo-fractionated palliative QUAD SHOT radiotherapy (RT) with concurrent cisplatin (CDDP) in previously untreated patients with incurable LAHNSCC.

MATERIALS/METHODS

In this prospective interventional phase- II study, 60 patients with locally advanced squamous cell carcinoma of the head and neck, majority stage IVB, ECOG PS ≤ 3, were treated with QUAD SHOT RT (14 Gy/4 fractions/2 days - BD with 6-hour interval and concurrent CDDP at 6 mg/m2. This treatment was repeated at 4-week intervals for 2 additional cycles if tumor progression did not occur. Serial changes in HR -QoL were assessed using EORTC QLQ C-30 and H&N-35) at 4 different time points. Statistical methods such as the Wilcoxon signed-rank test and Friedman test were used to compare QoL values at different time points with Bonferroni correction for multiple comparisons to control for type I errors.

RESULTS

The median global health score (GHS) at baseline was 41.667, with an initial increase in score at 4 weeks (50.00) and at 8 weeks (54.167) that did not continue at 12 weeks (41.667). Symptoms related to toxicities (speech, social contact, sticky saliva, dry mouth, senses in H&N 35) were lower after 4 weeks. Application of the Friedman test for four time points revealed significant improvement in role function at 4 weeks, which remained constant at 8 weeks but was not sustained at 12 weeks. Comparison of HN-35 symptom scores between the four time points showed improvement in symptoms such as pain, swallowing, and mouth opening at 4 and 8 weeks. The mean QLQ C30 summary score for these patients improved at four weeks but did not remain constant at 8 and 12 weeks.

CONCLUSION

Our study showed significant improvement in quality-of-life parameters and reduction in symptom burden at 4 and 8 weeks due to disease control and symptom palliation by QUADSHOT CTRT, while quality-of-life scores worsened and symptom scores were not maintained at 12 weeks due to disease progression and occurrence of acute toxicities. This phase II study may serve as the basis for designing a phase III randomized control trial to compare quality of life changes with QUADSHOT CTRT and other palliative CTRT regimens.

Predictive Value of Dynamic Tumor Volume Changes in Stage III Non-Small Cell Lung Cancer Treated with Chemoradiation and Consolidative Immunotherapy

PURPOSE/OBJECTIVE(S)

Concurrent chemoradiation (CRT) followed by Immunotherapy is standard of care in unresectable, locally advanced, non-small cell lung cancer (NSCLC). We hypothesize that on-treatment dynamic changes in tumor volume may predict oncologic outcome in Stage III NSCLC.

MATERIALS/METHODS

Stage III NSCLC patients who were treated with definitive CRT of 60 Gy in 30 fractions over 6 weeks with concurrent platinum-based concurrent chemotherapy followed by consolidative immunotherapy were retrospectively reviewed. We manually delineated the gross tumor volumes (GTV) of patients on cone beam computed tomography (CBCT) acquired on day 1, 15, 29 and 43. GTV reduction was quantified as the percent difference in volume on each CBCT as compared to CBCT Day 1. Mid-treatment response (MTR) and End of treatment response (ETR) was defined at day 29 (at 40 Gy) and day 43 (at 60 Gy), respectively. Loco-regional control (LRC) and overall survival (OS) was evaluated by Kaplan-Meier analysis, with log-rank test for groups stratified as per treatment response. Multivariate Cox regression analysis was performed to identify additional prognostic factors.

RESULTS

We evaluated 24 consecutively treated patients from 01/2016 to 08/2019, with a median follow-up of 30.5 months. Median age was 69 years (range 51-84). Adenocarcinoma histology was present in 58 % and squamous cell carcinoma in 42% patients. The tumor stage IIIA in 38% and Stage IIIB in 62% patients. All patients received definitive CRT with at least 2 cycles of immunotherapy (median 8 cycles). The median ETR at CBCT43 was 49.5% (range, 1%-84.7%). 1-year cumulative incidence of loco-regional failure (LRF) was 27% versus 10% in patients with ETR <49.5% as compared to patients with greater ETR (p = 0.31). The median MTR at CBCT29 was 32.7% (range, 1%-81%). 1-year cumulative incidence of LRF was 28% versus 9% in patients MTR <32.7% as compared to patients with higher response (p = 0.03). The 3-year actuarial LRC of all patients was 51% which was significantly better in higher MTR (70% vs 30%; p = 0.02, log-rank) as compared to lower MTR. The 3-year actuarial OS for all patients was 45% which was 54% in patients with higher MTR verses 37% in low responders (p = 0.09). On multivariate analysis, age and T-stage were significant factors associated with LRC. Histologic subtype showed no impact on our findings.

CONCLUSION

Stage III NSCLC patients with approximately one-third (33%) reduction of GTV on mid-treatment CBCT during CRT have significantly improved LRC and a trend towards improved OS. This approach may justify early adaptive intensification of RT or application of additional therapies in patients with non-optimal response. Additional large prospective study of CBCT is needed to determine whether treatment can be tailored based on tumor response, to improve outcomes.