Demographics, clinical profile, management, and outcome of retinoblastoma in a tertiary care center in southern India

20011

Background: Retinoblastoma is the most common malignant intraocular tumor in children. The estimated incidence of retinoblastoma in India is about 2,000 a year. However, there is scant data on the clinical manifestations and outcome of retinoblastoma in India. Methods: In this retrospective case series, the medical records of 460 consecutive cases of retinoblastoma from January 1990 to December 2004 were analyzed for demographics, clinical profile, treatment and outcome (survival, organ and function salvage). Results: An integrated Ocular Oncology Service was established at the treatment center in the year 2000 and a specialized Children’s Eye Cancer Center was founded in 2004. The annual referral increased from <20 a year before 2000 to 38 in 2000, and 120 in 2005. Two hundred and six (45%) patients were economically underprivileged. A majority (303, 66%) presented <3 years of age. There were 277 (60%) males. Although 188 (41%) were bilateral, family history was forthcoming in only 19 (4%). Of 648 involved eyes, 531 (82%) eyes were symptomatic. Leucocoria (71%) was the most common symptom, followed by visual loss (12%), eyelid edema or proptosis (7%), squint (6%), pain (2%), redness (2%), enlarged eyeball (2%), or shrunken eyeball (1%). The tumor was intraocular in 609 (94%) eyes while 39 (6%) were extraocular. Enucleation was the most common primary treatment for intraocular retinoblastoma (236 of 451, 52%), followed by chemoreduction coupled with focal therapy (26%), focal therapy alone (11%), external beam radiation (55) or chemotherapy alone (4%). Histopathologic risk factors predictive of metastasis were found in 152 of 277 (55%) eyes that underwent enucleation. Chemoreduction with focal therapy resulted in eye and vision salvage in 109 of 118 (92%). At the final follow-up (minimum 24 months), 434 (94%) were alive and well. Conclusions: Retinoblastoma has excellent prognosis for survival, eye salvage and vision salvage with the current management modalities. An integrated approach involving a team of a pediatric oncologist and an ocular oncologist at a comprehensive tertiary care center may augment referrals and help implement systematic treatment strategies.

No significant financial relationships to disclose.

The impact of intra-operative high field magnetic resonance imaging on clinical decision making during oncologic neurosurgical procedures

19599

Background: Existing image guided surgical (IGS) technology used during resection of brain tumors is based on preoperative imaging modalities and are limited by their inability to demonstrate extent of resection (EOR) and compensate for anatomical changes which occur as a result of surgical manipulation (e.g. brain shift, tumor resection, spinal fluid loss). Having the ability to perform MRI during brain tumor surgery obviates many of these limitations. The purpose of this study was to determine the impact of intra-operative imaging with a high field MRI on brain tumor resection. Methods: Since September 2006, a total of 23 patients with brain tumors underwent resection at The University of Texas M. D. Anderson Cancer Center with intra-operative MR guidance (BrainLAB IGS system integrated with a 1.5T Siemens Espree scanner). For each patient, appropriate imaging was performed prior to craniotomy. Resection was then performed using image guidance. Surgeons completed a questionnaire documenting the reason for the scan and provided an estimation of EOR prior to and after the intraoperative scan. Multiple intraoperative scans were performed at the discretion of the operating surgeon. Results: In 23 patients, 25 scans were performed. The patients had a diagnosis of glioma (21), lymphoma (1), and schwannoma (1). Reasons for performing a scan included: evaluate EOR in 23 (92%) or update the IGS system in 2 (8%). Surgeons indicated in 21/23 (91%) scans performed to evaluate the extent of resection that they would have terminated the surgery prior to the scan. In 9/21 cases (43%), further surgery was performed after the scan to maximize EOR. In 10/24 (42%) cases, the pre-scan estimate of residual tumor matched the post-scan amount. The amount of residual tumor was correctly assessed (within 10%) prior to review of the MRI in 19/24 cases. The correlation between the pre-scan estimation of residual tumor and actual post-scan tumor was high (correlation coefficient 0.81, p<0.05). Conclusions: High field intra- operative MRI with high spatial resolution is a useful adjunct to a neurosurgical oncology practice and alters surgical decision making in a significant number of cases.

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The major lung cancer-derived mutants of ERBB2 are oncogenic and are associated with sensitivity to the irreversible EGFR/ERBB2 inhibitor HKI-272

Mutations in the ERBB2 gene were recently found in approximately 2% of primary non-small cell lung cancer (NSCLC) specimens; however, little is known about the functional consequences and the relevance to responsiveness to targeted drugs for most of these mutations. Here, we show that the major lung cancer-derived ERBB2 mutants, including the most frequent mutation, A775insYVMA, lead to oncogenic transformation in a cellular assay. Murine cells transformed with these mutants were relatively resistant to the reversible epidermal growth factor receptor (EGFR) inhibitor erlotinib, resembling the resistant phenotype found in cells carrying the homologous mutations in exon 20 of EGFR. However, the same cells were highly sensitive to the irreversible dual-specificity EGFR/ERBB2 kinase inhibitor HKI-272, as were those overexpressing wild-type ERBB2. Finally, the NSCLC cell line, Calu-3, overexpressing wild-type ERBB2 owing to a high-level amplification of the ERBB2 gene were highly sensitive to HKI-272. These results provide a rationale for treatment of patients with ERBB2-mutant or ERBB2-amplified lung tumors with HKI-272.

An in-vitro investigation of the effect of a water additive and a new acidic primer on the tensile bond strength of composite resin to human enamel and dentine

The aim of this study was to investigate the effect of a water additive on the bond strength of a composite restorative material to enamel and dentine which have undergone a range of surface treatments regimes. Human enamel and dentine specimens were prepared and divided into 3 surface treatment groups. Composite resin restorative material was bonded to the surface prepared enamel and dentine specimens. The tensile bond strength of the composite resin was measured using a Lloyd's testing machine. The tensile bond strength of composite resin to etched enamel surfaces using a standard etch technique was significantly greater than that to dentine (p < 0.05). For those specimens subjected to the addition of the water additive 'Alpron' the bond strength to the enamel was still significantly greater than to the dentine (p< 0.005). The addition of 'Alpron' to the water significantly improved the bond strength of composite to enamel and dentine when etched and placed with 'Prime&BondNT' (p < 0.05). There was no significant difference in bond strength of enamel and dentine specimens bonded using Xeno III (p> 0.05). However, the bond strength of dentine specimens bonded with Xeno III was significantly greater than other dentine specimens bonded with Prime&BondNT (p< 0.05). For those groups of specimens which included the water additive 'Alpron' in the regime, the tensile bond strength of the composite resin restorative material to enamel and dentine was greater than for those non water additive groups. The tensile bond strength of composite resin bonded to enamel surfaces prepared with 'Alpron' was significantly higher than that bonded to dentine surfaces.

Selective laser trabeculoplasty versus argon laser trabeculoplasty: results from a 1-year randomised clinical trial

AIMS

To compare selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT), in terms of intraocular pressure (IOP) lowering, in patients with open-angle glaucoma.

METHODS

176 eyes of 152 patients were enrolled in this study, 89 in the SLT and 87 in the ALT groups. Patients were randomised to receive either SLT or ALT treatment to 180 degrees of the trabecular meshwork. Patients were followed up to 12 months after treatment. The main outcome measured was IOP lowering at 12 months after treatment, compared between the SLT and ALT groups.

RESULTS

No significant difference (p = 0.846) was found in mean decrease in IOP between the SLT (5.86 mm Hg) and ALT (6.04 mm Hg) groups at 1 year or at any other time points, nor were there any significant differences in the rate of early or late complications between the two groups.

CONCLUSIONS

SLT is equivalent to ALT in terms of IOP lowering at 1 year, and is a safe and effective procedure for patients with open-angle glaucoma.

Human papillomavirus genotypes associated with cervical neoplasia in India

The aim of this study was to determine the prevalence of human papillomavirus (HPV) genotypes in tissue with cervical neoplasias in patients from south and east India. Cross-sectional cervical tissue was obtained from 100 patients from south India and 30 patients from east India who had a biopsy for clinically invasive cervical cancer or cervical intraepithelial neoplasia (CIN) in a tertiary care hospital in India. DNA amplification was done with biotinylated PGMY 09/11 primers, and the line blot assay was used to determine the HPV genotype. HPV DNA was detected in 95% of invasive cancers (113/119) and 91% of CINs (10/11). A single HPV type was found in 100 women (77%), and mixed infections were found in 23 women (18%). HPV 16 (60%) and HPV 18 (14%) were the most frequent types, but 16 other types (26, 31, 33, 35, 42, 45, 51, 52, 53, 56, 58, 61, 62, 64, 81, and 82) were also identified. HPV 16 was present in 63% of patients from south India and in 50% of patients from east India, while HPV 18 was present in 12% and 20%, respectively. There are several high-risk HPV types associated with cervical neoplasias of which types 16 and 18 are the most common.

Langerhan's Cell Histiocystosis - a case report

Langerhan's Cell Histiocystosis - a case report Diagnostic challenge in a 21/2 years age girl: A cliniceo-radio-pathological correlation

Clinical guidelines to diagnose smear-negative pulmonary tuberculosis in Pakistan, a country with low-HIV prevalence

OBJECTIVES

To develop and validate clinical guidelines for diagnosis of smear-negative pulmonary tuberculosis (TB) in developing countries with low-HIV prevalence.

METHODS

We developed diagnostic guidelines for smear-negative TB. Clinical diagnoses based on these guidelines were compared with sputum culture, chest X-rays and reports of an expert panel.

RESULTS

The guidelines achieved a sensitivity of 0.59 [confidence interval (CI) 0.46-0.66] and a specificity of 0.86 (CI 0.84-0.88) in diagnosing smear-negative TB. A total of 6.8% of patients who initially improved after a course of antibiotics were later confirmed to have TB. Clinicians detected an abnormal chest X-ray in 92% (CI 88-96%) and radiological signs of pulmonary TB in 98% (CI 94-100%) of cases.

CONCLUSIONS

Our experience highlights a number of dilemmas faced in developing, testing and implementing diagnostic guidelines in poorly resourced conditions. Using radiological criteria for TB and appropriate training can help in improving the diagnostic skills of primary care clinicians working in low-HIV settings with access to X-ray facilities. But a significant number of apparently smear-negative TB cases may in fact be smear positive and TB programmes should focus on improving the quality of direct acid-fast bacilli microscopy. The value of an antibiotic trial is questionable due to the relatively large number of false negatives generated by this approach.

Identification to the species level and differentiation between strains of Aspergillus clinical isolates by automated repetitive-sequence-based PCR

A commercially available repetitive-sequence-based PCR (rep-PCR) DNA fingerprinting assay adapted to an automated format, the DiversiLab system, enables rapid microbial identification and strain typing. We explored the performance of the DiversiLab system as a molecular typing tool for 69 Aspergillus isolates (38 A. fumigatus, 15 A. flavus, and 16 A. terreus isolates) had been previously characterized by morphological analysis. Initially, 27 Aspergillus isolates (10 A. fumigatus, 9 A. flavus, and 8 A. terreus isolates) were used as controls to create a rep-PCR-based DNA fingerprint library with the DiversiLab software. Then, 42 blinded Aspergillus isolates were typed using the system. The rep-PCR-based profile revealed 98% concordance with morphology-based identification. rep-PCR-based DNA fingerprints were reproducible and were consistent for DNA from both hyphae and conidia. DiversiLab dendrogram reports correctly identified all A. fumigatus (n = 28), A. terreus (n = 8), and A. flavus (n = 6) isolates in the 42 blinded Aspergillus isolates. rep-PCR-based identification of all isolates was 100% in agreement with the contiguous internal transcribed spacer (ITS) region (ITS1-5.8S-ITS2) sequence-based identification of the respective isolates. Additionally, the DiversiLab system could demonstrate strain-level differentiation of A. flavus and A. terreus. Automated rep-PCR may be a time-efficient, effective, easy-to-use, novel genotyping tool for identifying and determining the strain relatedness of fungi. This system may be useful for epidemiological studies, molecular typing, and surveillance of Aspergillus species.

Molecular imaging of gene therapy for cancer

Gene therapy of cancer has been one of the most exciting and elusive areas of scientific and clinical research in the past decade. One of the most critical issues for ensuring success of this therapy is the development of technology for noninvasive monitoring of the location, magnitude and duration of vector-mediated gene expression, as well as the distribution and targeting of vector particles in vivo. In recent years many advances have been made in high-resolution, in vivo imaging methods, including: radionuclide imaging, such as positron emission tomography (PET) and single photon emission tomography (SPECT), magnetic resonance (MR) imaging and spectroscopy, bioluminescence imaging and various fluorescence imaging techniques, including fluorescence-mediated tomography (FMT) and near-infrared fluorescence (NIRF) reflectance imaging. A variety of factors determine the choice of specific imaging system, some of them are the imaging requirements (single or repeated), intended use (animal or human) and spatial requirements (organs versus cellular resolution and depth). This review provides descriptions of modalities applicable to imaging different parameters of vector-mediated gene expression in tumors and stem cell tracking in vivo.

Circulating human plasmacytoid dendritic cells are highly sensitive to corticosteroid administration

Plasmacytoid dendritic cells (pDC), the major interferon-producing cell type found in human blood, have been implicated in the pathogenesis of systemic lupus erythematosus (SLE). Previous studies in SLE have shown substantial deviations from normal in this minor but immunologically important leukocyte population. Many of the lupus patients studied were receiving corticosteroids. To determine the effects of steroid administration on pDC in healthy adults, four volunteers were given prednisone, 15-30 mg daily, for 4 days. Both counts of pDC, and their ability to produce IFN-alpha were significantly reduced (P = 0.02 and 0.004, respectively) during steroid administration, and rapidly recovered after discontinuation of the hormones. The overall reduction in pDC-derived IFN appeared to be attributable to falls of both number of circulating cells and of IFN produced per pDC. The effects observed with pDC were comparable in magnitude but opposite in direction to that observed for granulocytes. In contrast other blood leukocytes were little affected during steroid therapy.