Optimizing multimodality treatment for head and neck cancer in rural India

BACKGROUND

Multimodality treatment of head and neck cancer in rural India is not always feasible due to lack of infrastructure and logistics.

AIM

To demonstrate the feasibility of multimodality treatment for head and neck cancer in a community setting in rural India.

SETTING AND DESIGN

Community cancer center, retrospective review.

MATERIALS AND METHODS

This article focuses on practice environment in a cancer clinic in rural India. We evaluated patient profile, treatment protocols, infrastructure availability, factors impacting treatment decisions, cost estimations, completion of treatment, and major treatment-related complications for the patient population treated in our clinic for a 2-year period.

RESULTS

A total of 230 head and neck cancer patients were treated with curative intent. Infrastructure support included basic operating room facility (cautery machine, suction, drill system, microscope, and anesthesia machine without ventilator support), blood bank, histopathology laboratory, and computerized tomography machine. Radiation therapy (RT) facility was available in a nearby city, about 75 km away. One hundred and fifty-four (67%) patients presented at an advanced stage, with 138 (60%) receiving multimodality treatment. One hundred and eighty-four (80%) patients underwent primary surgery and 167 (73%) received radiotherapy. Two hundred and twelve (92%) patients completed the treatment, 60 (26%) were lost to follow-up at 18-month median follow-up (range 12-26 months), with 112 patients (66%) being alive, disease free. Totally 142 were major head neck surgeries with 25 free flap reconstructions and 41 regional flaps. There were 15 (6%) major post-op complications and two perioperative mortalities. Average cost of treatment for single modality treatment was approximately 40,000 INR and for multimodality treatment was 80,000 INR.

CONCLUSIONS

This study demonstrates that it is feasible to provide basic multimodality treatment to head and neck cancer patients in the community.

Citrus huanglongbing: a newly relevant disease presents unprecedented challenges

Citrus huanglongbing (HLB) is one of the oldest citrus diseases and has been known for over a century. HLB is caused by 'Candidatus Liberibacter' spp. that are phloem-limited, fastidious α-proteobacteria and infect hosts in different Kingdoms (i.e., Animalia and Plantae). When compared with well-characterized, cultivatable plant-pathogenic Gram-negative bacteria, the interactions of uncultured insect-vectored plant-pathogenic bacteria, including 'Ca. Liberibacter' spp., with their hosts remain poorly understood. 'Ca. Liberibacter' spp. have been known to cause HLB, which has been rapidly spreading worldwide, resulting in dramatic economic losses. HLB presents an unprecedented challenge to citrus production. In this review, we focus on the most recent research on citrus, 'Candidatus Liberibacter asiaticus', and psyllid interactions, specifically considering the following topics: evolutionary relationships among 'Ca. Liberibacter' spp., genetic diversity, host range, genome analysis, transmission, virulence mechanisms, and the ecological importance of HLB. Currently, no efficient management strategy is available to control HLB, although some promising progress has been made. Further studies are needed to understand citrus, 'Ca. L. asiaticus', and psyllid interactions to design innovative management strategies. Although HLB has been problematic for over a century, we can only win the battle against HLB with a coordinated and deliberate effort by the citrus industry, citrus growers, researchers, legislatures, and governments.

EBV stimulates TLR- and autophagy-dependent pathways and impairs maturation in plasmacytoid dendritic cells: implications for viral immune escape

Plasmacytoid DCs (pDCs) are crucial mediators in the establishment of immunity against most viruses, given their extraordinary capacity to produce a massive quantity of type I IFN. In this study we investigate the response of pDCs to infection with EBV, a γ-herpes virus that persists with an asymptomatic infection in immunocompetent hosts, although in certain conditions it can promote development of cancers or autoimmune diseases. We show that high amounts of type I IFNs were released from isolated pDCs after exposure to EBV by a mechanism requiring TLRs and a functional autophagic machinery. We next demonstrate that EBV can infect pDCs via viral binding to MHC class II molecule HLA-DR and that pDCs express EBV-induced latency genes. Furthermore, we observe that EBV is able to induce activation but not maturation of pDCs, which correlates with an impaired TNF-α release. Accordingly, EBV-infected pDCs are unable to mount a full T-cell response, suggesting that impaired pDC maturation, combined with a concomitant EBV-mediated upregulation of the T-cell inhibitory molecules B7-H1 and ICOS-L, could represent an immune-evasion strategy promoted by the virus. These mechanisms might lead to persistence in immunocompetent hosts or to dysregulated immune responses linked to EBV-associated diseases.

MicroRNA-142 is mutated in about 20% of diffuse large B-cell lymphoma

MicroRNAs (miRNAs) are short 18–23 nucleotide long noncoding RNAs that posttranscriptionally regulate gene expression by binding to mRNA. Our previous miRNA profiling of diffuse large B-cell lymphoma (DLBCL) revealed a mutation in the seed sequence of miR-142-3p. Further analysis now showed that miR-142 was mutated in 11 (19.64%) of the 56 DLBCL cases. Of these, one case had a mutation in both alleles, with the remainder being heterozygous. Four mutations were found in the mature miR-142-5p, four in the mature miR-142-3p, and three mutations affected the miR-142 precursor. Two mutations in the seed sequence redirected miR-142-3p to the mRNA of the transcriptional repressor ZEB2 and one of them also targeted the ZEB1 mRNA. However, the other mutations in the mature miR-142-3p did not influence either the ZEB1 or ZEB2 3′ untranslated region (3′ UTR). On the other hand, the mutations affecting the seed sequence of miR-142-3p resulted in a loss of responsiveness in the 3′ UTR of the known miR-142-3p targets RAC1 and ADCY9. In contrast to the mouse p300 gene, the human p300 gene was not found to be a target for miR-142-5p. In one case with a mutation of the precursor, we observed aberrant processing of the miR-142-5p. Our data suggest that the mutations in miR-142 probably lead to a loss rather than a gain of function. This is the first report describing mutations of a miRNA gene in a large percentage of a distinct lymphoma subtype.

Development of a diagnostic system for Burkholderia pseudomallei infections

Monoclonal antibodies were generated against whole cell lysate of Burkholderia pseudomallei. Two out of 6 monoclonal antibodies were found specific and exhibited high affinity against B. pseudomallei, one of which, was utilized to develop sandwich ELISA for detection of specific B. pseudomallei antigen. Immunoassays were found to be specific as no reaction was observed with closely related Burkholderia and Pseudomonas species. Blood samples from experimentally infected mice were found positive for isolation till 4 days post infection (DPI) and ELISA till 10 DPI. One out of 40 sick animal serum samples tested in Thailand was found positive by sandwich ELISA that was earlier confirmed by isolation of B. pseudomallei. The results indicate the potentiality of the assay for its applicability in specific diagnosis of septicaemic melioidosis.

Identification of small molecule inhibitors against SecA of Candidatus Liberibacter asiaticus by structure based design

Huanglongbing is the most devastating disease of citrus caused by Candidatus Liberibacter asiaticus (Las). In the present study, we report the discovery of novel small molecule inhibitors against SecA ATPase of Las by using structure based design methods. We built the homology model of SecA protein structure of Las based on the SecA of Escherichia coli. The model was used for in-silico screening of commercially available compounds from ZINC database. Using the glide flexible molecular docking method, twenty structures were chosen for in vitro studies. Five compounds were found to inhibit the ATPase activity of SecA of Las at nano molar concentrations and showed antimicrobial activities against Agrobacterium tumefaciens with MBC ranging from 128 to 256 μg/mL. These compounds appear to be suitable as lead compounds for further development of antimicrobial compounds against Las.

HHV-8 reduces dendritic cell migration through down-regulation of cell-surface CCR6 and CCR7 and cytoskeleton reorganization

BACKGROUND

For an efficient immune response against viral infection, dendritic cells (DCs) must express a coordinate repertoire of receptors that allow their recruitment to the sites of inflammation and subsequently to the secondary lymphoid organs in response to chemokine gradients.Several pathogens are able to subvert the chemokine receptor expression and alter the migration properties of DCs as strategy to escape from the immune control.

FINDINGS

Here we report the inhibitory effect of Human Herpesvirus 8 (HHV-8) on the migratory behavior of immature and mature DCs. We found that the virus altered the DC chemokine receptor expression and chemokine induced migration. Moreover HHV-8 was also able to interfere with basal motility of DCs by inducing cytoskeleton modifications.

CONCLUSION

Based on our findings, we suggest that HHV-8 is able to subvert the DC migration capacity and this represents an additional mechanism which interferes with their immune-functions.

Primary effusion lymphoma cell death induced by bortezomib and AG 490 activates dendritic cells through CD91

To understand how cytotoxic agent-induced cancer cell death affects the immune system is of fundamental importance to stimulate immune response to counteract the high mortality due to cancer. Here we compared the immunogenicity of Primary Effusion Lymphoma (PEL) cell death induced by anticancer drug Bortezomib (Velcade) and Tyrphostin AG 490, a Janus Activated Kinase 2/signal trasducer and activator of transcription-3 (JAK2/STAT3) inhibitor. We show that both treatments were able to induce PEL apoptosis with similar kinetics and promote dendritic cells (DC) maturation. The surface expression of molecules involved in immune activation, namely calreticulin (CRT), heat shock proteins (HSP) 90 and 70 increased in dying cells. This was correlated with DC activation. We found that PEL cell death induced by Bortezomib was more effective in inducing uptake by DC compared to AG 490 or combination of both drugs. However the DC activation induced by all treatments was completely inhibited when these cells were pretreated with a neutralizing antiboby directed against the HSP90/70 and CRT common receptor, CD91. The activation of DC by Bortezomib and AG 490 treated PEL cells, as seen in the present study, might have important implications for a combined chemo and immunotherapy in such patients.

A case study: application of statistical process control tool for determining process capability and sigma level

Statistical process control is the application of statistical methods to the measurement and analysis of variation process. Various regulatory authorities such as Validation Guidance for Industry (2011), International Conference on Harmonisation ICH Q10 (2009), the Health Canada guidelines (2009), Health Science Authority, Singapore: Guidance for Product Quality Review (2008), and International Organization for Standardization ISO-9000:2005 provide regulatory support for the application of statistical process control for better process control and understanding. In this study risk assessments, normal probability distributions, control charts, and capability charts are employed for selection of critical quality attributes, determination of normal probability distribution, statistical stability, and capability of production processes, respectively. The objective of this study is to determine tablet production process quality in the form of sigma process capability. By interpreting data and graph trends, forecasting of critical quality attributes, sigma process capability, and stability of process were studied. The overall study contributes to an assessment of process at the sigma level with respect to out-of-specification attributes produced. Finally, the study will point to an area where the application of quality improvement and quality risk assessment principles for achievement of six sigma-capable processes is possible.

LAY ABSTRACT

Statistical process control is the most advantageous tool for determination of the quality of any production process. This tool is new for the pharmaceutical tablet production process. In the case of pharmaceutical tablet production processes, the quality control parameters act as quality assessment parameters. Application of risk assessment provides selection of critical quality attributes among quality control parameters. Sequential application of normality distributions, control charts, and capability analyses provides a valid statistical process control study on process. Interpretation of such a study provides information about stability, process variability, changing of trends, and quantification of process ability against defective production. Comparative evaluation of critical quality attributes by Pareto charts provides the least capable and most variable process that is liable for improvement. Statistical process control thus proves to be an important tool for six sigma-capable process development and continuous quality improvement.

Lipoadenoma of the parathyroid gland - a rare cause of hyperparathyroidism

Lipoadenoma of parathyroid gland is an unusual morphologic variant of parathyroid adenoma in which the glandular elements are associated with abundant mature adipose tissue. The lesion has also been reported as parathyroid lipohyperplasia, parathyroid hamartoma, and parathyroid adenoma with myxoid stroma. Most cases are functioning and are associated with hyperparathyroidism. Lipoadenoma of parathyroid gland are difficult to diagnose as a cause of hyperparathyroidism because of rarity of these lesions and overlap with normal parathyroid tissue on microscopic evaluation. Only few cases have been documented in the literature so far. The lesion may be overlooked by both surgeon and pathologists alike, if they are not aware of this specific clinicopathologic entity.

Primary central nervous system lymphoma: a study of clinicopathological features and trend in western India

INTRODUCTION

Primary central nervous system lymphoma (PCNSL) is rare and accounts for 1-2% of all primary intracranial tumors (ICT). There are conflicting reports regarding the increased incidence of PCNSL over the last two decades in both immunocompromised and immunocompetent patients.

AIM

This study was designed to study the clinicopathological characteristics of PCNSL and to access the trend of PCNSL at our institute.

MATERIALS AND METHODS

All the histopathologically proven cases of PCNSL were reviewed from January 1997 to December 2009 (13 years). Immunophenotyping was performed on available paraffin-embedded tissue blocks. Immune status was evaluated and human immunodeficiency virus (HIV) serology was performed in all cases. Cerebrospinal fluid (CSF) findings were recorded whenever available. Possibility of secondary involvement by a systemic lymphoma was excluded in every case. Statistical analysis was done using χ2 -test.

RESULTS

During the study period (13 years), a total of 4715 cases of ICT were diagnosed, out of which 66 cases were PCNSL, which accounted for 1.4%. The age ranged from 10 to 75 years with a median age of 46 years. All the patients were immunocompetent. Frontal lobe was the most common site of involvement. Diffuse large B-cell lymphoma was the histological pattern in all the cases. CSF involvement was seen in only one case.

CONCLUSIONS

In this study, no significant increase in the incidence of PCNSL was found at our institute. Association of PCNSL cases with HIV or acquired immunodeficiency syndrome was not found in our study.

Effect of rectal distension on voluntary external anal sphincter function in healthy subjects

AIM

Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure.

METHOD

Fifty-seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50-ml distensions (n=35) or isobaric 4-mmHg distensions (n=22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure.

RESULTS

The distension-induced squeeze increment was calculated as the maximum percentage increase in maximum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean ± standard deviation (range) increase of 32.8 ± 24.1 (-5.5 to 97.7)%. The mean ± standard deviation (range) distension-induced squeeze increment in male subjects was 36.1 ± 25.7 (-5.5 to 97.7)% and in female subjects was 28.1 ± 20.1 (-3.8 to 70.2)%. There was no significant difference between the sexes (P=0.194).

CONCLUSION

Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.

Isolation and characterization of beneficial bacteria associated with citrus roots in Florida

Cultivable diversity of bacteria associated with citrus was investigated as part of a larger study to understand the roles of beneficial bacteria and utilize them to increase the productive capacity and sustainability of agro-ecosystems. Citrus roots from Huanglongbing (HLB) diseased symptomatic and asymptomatic citrus were used in this study. A total of 227 and 125 morphologically distinct colonies were isolated and characterized from HLB asymptomatic and symptomatic trees, respectively. We observed that the frequency of bacterial isolates possessing various plant beneficial properties was significantly higher in the asymptomatic samples. A total of 39 bacterial isolates showing a minimum of five beneficial traits related to mineral nutrition [phosphate (P) solubilization, siderophore production, nitrogen (N) fixation], development [indole acetic acid (IAA) synthesis], health [production of antibiotic and lytic enzymes (chitinase)], induction of systemic resistance [salicylic acid (SA) production], stress relief [production of 1-amino-cyclopropane-1-carboxylate deaminase] and production of quorum sensing [N-acyl homoserine lactones] signals were characterized. A bioassay using ethidium monoazide (EMA)-qPCR was developed to select bacteria antagonistic to Candidatus Liberibacter asiaticus. Using the modified EMA-qPCR assay, we found six bacterial isolates showing maximum similarity to Paenibacillus validus, Lysinibacillus fusiformis, Bacillus licheniformis, Pseudomonas putida, Microbacterium oleivorans, and Serratia plymutica could significantly reduce the population of viable Ca. L. asiaticus in HLB symptomatic leaf samples. In conclusion, we have isolated and characterized multiple beneficial bacterial strains from citrus roots which have the potential to enhance plant growth and suppress diseases.

Huanglongbing alters the structure and functional diversity of microbial communities associated with citrus rhizosphere

The diversity and stability of bacterial communities present in the rhizosphere heavily influence soil and plant quality and ecosystem sustainability. The goal of this study is to understand how 'Candidatus Liberibacter asiaticus' (known to cause Huanglongbing, HLB) influences the structure and functional potential of microbial communities associated with the citrus rhizosphere. Clone library sequencing and taxon/group-specific quantitative real-time PCR results showed that 'Ca. L. asiaticus' infection restructured the native microbial community associated with citrus rhizosphere. Within the bacterial community, phylum Proteobacteria with various genera typically known as successful rhizosphere colonizers were significantly greater in clone libraries from healthy samples, whereas phylum Acidobacteria, Actinobacteria and Firmicutes, typically more dominant in the bulk soil were higher in 'Ca. L. asiaticus'-infected samples. A comprehensive functional microarray GeoChip 3.0 was used to determine the effects of 'Ca. L. asiaticus' infection on the functional diversity of rhizosphere microbial communities. GeoChip analysis showed that HLB disease has significant effects on various functional guilds of bacteria. Many genes involved in key ecological processes such as nitrogen cycling, carbon fixation, phosphorus utilization, metal homeostasis and resistance were significantly greater in healthy than in the 'Ca. L. asiaticus'-infected citrus rhizosphere. Our results showed that the microbial community of the 'Ca. L. asiaticus'-infected citrus rhizosphere has shifted away from using more easily degraded sources of carbon to the more recalcitrant forms. Overall, our study provides evidence that the change in plant physiology mediated by 'Ca. L. asiaticus' infection could elicit shifts in the composition and functional potential of rhizosphere microbial communities. In the long term, these fluctuations might have important implications for the productivity and sustainability of citrus-producing agro-ecosystems.

Laparoscopic kidney transplantation: an initial experience

Laparoscopic donor nephrectomy has the advantages of less pain, early ambulation and shorter hospitalization compared to open donor nephrectomy. Kidney recipient surgery is, however, traditionally performed by open surgery. Our aim was to study feasibility and safety of laparoscopic kidney transplantation (LKT). After permission from Internal Review Board, LKT was performed in four patients. All kidneys were procured from deceased donors. Left kidney was used for LKT and transplanted in left iliac fossa while right kidney was used for standard open kidney transplantation (OKT). All transplantation procedures were performed successfully. Cold ischemia time varied between 4 h and 14 h. For LKT, mean time for anastomosis was 65 (range 62-72) min, mean operative time was 3.97 (range 3.5-5) h, mean blood loss was 131.25 mL (range 45-350) mL. Mean wound length was 7 cm in LKT group and 18.4 cm in OKT group. Delayed graft function was observed in one patient in each group. One patient was lost in OKT group due to posttransplant bacterial meningitis. At 6 months, both groups have comparable value of serum creatinine. In conclusion, LKT is technically feasible and safe. Long term outcome needs to be evaluated in a larger study.

microRNA profiling in Epstein-Barr virus-associated B-cell lymphoma

The Epstein–Barr virus (EBV) is an oncogenic human Herpes virus found in ∼15% of diffuse large B-cell lymphoma (DLBCL). EBV encodes miRNAs and induces changes in the cellular miRNA profile of infected cells. MiRNAs are small, non-coding RNAs of ∼19–26 nt which suppress protein synthesis by inducing translational arrest or mRNA degradation. Here, we report a comprehensive miRNA-profiling study and show that hsa-miR-424, -223, -199a-3p, -199a-5p, -27b, -378, -26b, -23a, -23b were upregulated and hsa-miR-155, -20b, -221, -151-3p, -222, -29b/c, -106a were downregulated more than 2-fold due to EBV-infection of DLBCL. All known EBV miRNAs with the exception of the BHRF1 cluster as well as EBV-miR-BART15 and -20 were present. A computational analysis indicated potential targets such as c-MYB, LATS2, c-SKI and SIAH1. We show that c-MYB is targeted by miR-155 and miR-424, that the tumor suppressor SIAH1 is targeted by miR-424, and that c-SKI is potentially regulated by miR-155. Downregulation of SIAH1 protein in DLBCL was demonstrated by immunohistochemistry. The inhibition of SIAH1 is in line with the notion that EBV impedes various pro-apoptotic pathways during tumorigenesis. The down-modulation of the oncogenic c-MYB protein, although counter-intuitive, might be explained by its tight regulation in developmental processes.

Dendritic Cell Differentiation Blocked by Primary Effusion Lymphoma-Released Factors is Partially Restored by Inhibition of P38 MAPK

To better understand the molecular mechanisms underlying the dendritic cell (DC) defects in cancer, we analyzed which signaling pathway is implicated in the abnormal monocyte differentiation into DC determined by the presence of Primary effusion lymphoma (PEL) released factors. Our results indicate that the DC, obtained in this condition, together with phenotypic abnormalities and reduced allostimulatory function, showed hyperphosphorylation of signal transducer and activator of transcription 3 (STAT3) and p38 mitogen-activated protein kinase (MAPK) molecules, in comparison to the DC differentiated in the absence of PEL-released factors. The inhibition of p38 MAPK but not of STAT3 phosphorylation, with specific inhibitors, was able to revert the effect of the PEL-released factors on the DC phenotype. This study suggests that p38 MAPK signaling pathway is an important contributor to the abnormal differentiation of DC in PEL.

Modified laparoscopic abdominal vesico-vaginal fistula repair--"Mini-O'Conor" vesicotomy

AIM

The aim of this work was to report on our experience with the laparoscopic repair of vesicovaginal fistulae and describe a modification in technique.

PATIENTS AND METHODS

Between 2004 and 2008, 8 patients underwent laparoscopic repair of vesicovaginal fistula. All patients had fistulae secondary to gynecologic surgery. Two patients had undergone previous failed attempts at repair. The mean interval prior to repair was 3.5 months. Patient underwent repair by using a limited cystotomy.

RESULTS

The operation was successfully completed in all cases. Mean operative time was 145 minutes, and mean estimated blood loss 60 mL. There were no complications. Catheter removal was done at 14 days. All patients were continent after catheter removal and remained continent at a mean follow-up of 29 months.

CONCLUSION

Laparoscopic repair of vesicovaginal fistula is safe and effective. Bivalving of the bladder may be avoided by use of a small cystotomy, with the potential benefits of shorter operative time and reduced bladder spasms.

Laparoscopic pyelovesicostomy for giant hydronephrosis in a solitary kidney

Pyelovesicostomy has rarely been described in the literature. Most of the time this procedure has been performed in cases of ureteral obstruction in an ectopic kidney or in a transplanted kidney. We report the case of a 16-year-old male who presented with a history of large abdominal swelling and pain. On investigation he was found to have a solitary right kidney with giant hydronephrosis and to be in renal failure. An initial percutaneous nephrolithotomy diversion was performed followed 1 month later by right laparoscopic pyelovesicostomy. The postoperative period was uneventful. We describe laparoscopic pyelovesicostomy in the management of giant hydronephrosis for the first time. Our case illustrates that laparoscopic pyelovesicostomy is a feasible option in the management of giant hydronephrosis.