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Wang J, Lin T, Reddy AV, Hill C, Sehgal S, McPhaul T, Herman JM, He J, Zheng L, Meyer JJ, Narang A. Pathway Mutations are Associated with Clinical Outcomes in Localized Pancreatic Cancer Treated with Neoadjuvant Chemoradiation Followed by Surgery. Int J Radiat Oncol Biol Phys 2023; 117:e348-e349. [PMID: 37785208 DOI: 10.1016/j.ijrobp.2023.06.2419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The purpose of this study was to determine if mutations in biological pathways are associated with clinical outcomes in patients with localized pancreatic cancer who undergo neoadjuvant chemoradiation followed by surgical resection. MATERIALS/METHODS Patients treated with neoadjuvant chemoradiation followed by oncologic resection from 2015-2019 who also underwent next generation sequencing (NGS) of the primary tumor were included in this retrospective analysis. NGS was done using either Foundation One (n = 20), in-house Solid Tumor Panel (n = 121), or Tempus XT (n = 1). Genes were included in pathway analysis if at least one patient harbored a mutation in the gene. Pathways were defined from the Molecular Signatures Database Hallmark, KEGG, and Reactome gene sets. A pathway was deemed mutated if at least one gene within the pathway was mutated. Univariable Cox regression was performed to determine the association between pathway mutation status and overall survival (OS) as well as progression-free survival (PFS). RESULTS In total, 142 patients met criteria for study inclusion. For pathway analysis, 329 genes met inclusion criteria. Patients were typically treated with neoadjuvant chemotherapy (either 5-fluorouracil-based or gemcitabine-based) followed by radiation. Patients received SBRT (n = 104, most commonly 33 Gy in 5 fractions) or conventionally fractionated radiation (n = 38, most commonly 50.4 Gy in 28 fractions). For clinical variables, worse OS was significantly associated with T stage (p = 0.036), N stage (p = 0.044), and lymphovascular invasion (LVI, p = 0.011); worse PFS was significantly associated with T stage (p = 0.0008), N stage (p = 0.022), LVI (p = 0.026), and conventional RT (p = 0.007). Mutations in major pathways were associated with worse OS, notably hedgehog signaling (p = 0.001), chromatin modifying enzymes (p = 0.002), WNT/beta-catenin signaling (p = 0.005), mismatch repair (0.006), E2F targets (p = 0.008), FLT signaling (p = 0.012), VEGF signaling (0.025), innate immune system (p = 0.026), and NOTCH signaling (p = 0.029). Pathway mutations associated with worse PFS included mismatch repair (p = 0.007) and hedgehog signaling (p = 0.013). CONCLUSION For pancreatic cancer patients that undergo neoadjuvant chemoradiation followed by oncologic resection of the primary tumor, mutations in key biological pathways are associated with OS and PFS. Characterizing the importance of common pathway mutations may become increasingly valuable to help categorize less commonly mutated genes assayed by NGS.
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Affiliation(s)
- J Wang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Johns Hopkins Medical Institute, Department of Radiation Oncology, Baltimore, MD
| | - T McPhaul
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Voong KR, Shokek OB, Hill C, Hu C, Hales RK, Greco SC, Meyer JJ, Wright JL, Lowe K, McNutt TR, Narang A, PhD CS, Lee SM. Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study. Int J Radiat Oncol Biol Phys 2023; 117:e264-e265. [PMID: 37785007 DOI: 10.1016/j.ijrobp.2023.06.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management. MATERIALS/METHODS We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms). RESULTS To be determined. CONCLUSION To be determined.
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Affiliation(s)
- K R Voong
- Johns Hopkins University, Baltimore, MD
| | - O B Shokek
- Wellspan York Cancer Center, York, PA, United States
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hu
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S C Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J L Wright
- Johns Hopkins Medicine, Department of Radiation Oncology, Baltimore, MD
| | - K Lowe
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Snyder PhD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - S M Lee
- Department of Biostatistics, Columbia University School of Medicine, New York, NY
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Madan V, Lin TA, Reddy AV, Hill C, Sehgal S, Hacker-Prietz A, McPhaul T, He J, Zheng L, Ngwa W, Herman JM, Meyer JJ, Narang A. Characterization of DNA Damage Response-Associated Somatic Mutations in Borderline Resectable and Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e321. [PMID: 37785147 DOI: 10.1016/j.ijrobp.2023.06.2361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The role of radiation for pancreatic cancer remains controversial, with recent studies showing conflicting results, highlighting the need to develop biomarkers of radiation response. Despite its potential utility in predicting radiosensitivity, the landscape of somatic mutations in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), as related to DNA damage response (DDR), has not been well characterized. This study aimed to characterize the frequency of such mutations in a cohort of patients with BRPC/LAPC treated with neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT). MATERIALS/METHODS Mutational data was collected from patients with BRPC/LAPC treated at a single institution with neoadjuvant chemotherapy and SBRT, followed by surgical resection from 2016-2021. Chemotherapy consisted of modified FOLFIRINOX or gemcitabine/nab-paclitaxel, and patients were treated with SBRT in 33 Gy in 5 fractions. Genomic data was obtained from either endoscopic biopsy or surgical specimens, and next-generation sequencing was performed either in-house with a Solid Tumor Panel or with FoundationOne CDx. Specific emphasis was placed on the characterization of double-strand DNA break (DSB) repair genes, as this is the type of tumor cell damage traditionally induced by radiation therapy. Genes associated with the two main pathways of DSB repair, non-homologous end joining (NHEJ) and homologous repair (HR), were analyzed. Specific HR pathway mutations assessed were BLM, BRCA1/2, MRE11, NBN, PALB2, RAD50, RAD51B-D, and RAD54L, while PRKDC mutations were assessed for the NHEJ pathway. Mutations in ATM, an important initiator of DDR pathways, were also analyzed. Additionally, the frequency of mutations in TP53, CDKN2A and SMAD4 in patients with concomitant KRAS mutations was assessed. RESULTS Eighty-five patients were included in the study. Five (5.9%) patients had mutations in the NHEJ pathway of the PRKDC gene. Twenty (23.5%) patients had mutations in the HR pathway, including BRCA2 (10/85; 11.8%), PALB2 (5/85; 5.9%), BRCA1 (3/85; 3.5%), and RAD50 (1/85; 1.2%). Six (7.1%) patients had mutations in ATM. No patients were found to have mutations in BLM, RAD51B-D, RAD54L, or NBN. Amongst patients with KRAS mutations (72/85), concomitant mutations were observed in TP53 (47/85; 55.3%), CDKN2A (16/85; 18.8%), and SMAD4 (9/85; 10.6%). CONCLUSION Herein, we characterized the frequency of somatic mutations associated with DSB repair genes in patients with BRPC/LAPC. Data analysis on outcomes related to radiation response in patients with mutations in DDR pathways is ongoing, but will likely also benefit from multi-institutional efforts to increase the power to answer this question.
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Affiliation(s)
- V Madan
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Johns Hopkins Medical Institute, Department of Radiation Oncology, Baltimore, MD
| | - A Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T McPhaul
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - W Ngwa
- John Hopkins University Hospital, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Mao S, Lin TA, Sehgal S, Reddy AV, Hill C, Herman JM, Meyer JJ, Narang A. Utilization of the Triangle Volume in Patients with Localized PDAC Undergoing Pre-Operative SBRT: Report of Early Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:S14. [PMID: 37784357 DOI: 10.1016/j.ijrobp.2023.06.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) In patients with borderline resectable or locally advanced pancreatic adenocarcinoma (BRPC/LAPC), advances in neoadjuvant therapy have led to an increased proportion of patients undergoing margin negative resection. Nevertheless, locoregional recurrence rates remain high. We have previously reported that the location of locoregional recurrences in this setting map to the "Triangle Volume (TV)," the anatomical space between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein, which is enriched in extrapancreatic perineural tracts at risk for microscopic residual disease after resection. At the beginning of 2021, we systematically changed our target volume to include the TV, in addition to gross disease and involved vasculature. Herein, we report early locoregional failure outcomes after resection in the setting of BRPC or LAPC treated with pre-operative stereotactic body radiation therapy (SBRT) to the TV, as compared to historical rates. MATERIALS/METHODS Patients who received a diagnosis of BRPC or LAPC and who were treated at our institution with neoadjuvant chemotherapy (CTX) and SBRT between 2016 and 2022 were retrospectively reviewed. Between 2016 and 2020, the SBRT clinical tumor volume (CTV) included gross disease and full circumference of involved vasculature at the level of involvement. From 2021 onward, the CTV also included the TV. Survival was estimated using the Kaplan-Meier method. Statistical analyses were performed using scientific 2-D graphing and statistics software. RESULTS From January 2016 to December 2022, 204 patients with localized PDAC underwent neoadjuvant CTX followed by SBRT. After completion of SBRT, all patients proceeded with surgical exploration. Of these patients, 111 (54%) had LAPC and 92 (45%) had BRPC disease. All patients were treated with induction CTX, mostly commonly with FOLFIRINOX (N = 166, 81%). Following CTX, the most frequently used SBRT regimen was 33 Gy in 5 fractions (N = 191, 94%). 155 (67%) patients were treated between 2016 and 2020 to the traditional CTV, while 49 (24%) patients were treated after 2020 to a CTV that included the TV. The 2-year local progression free survival rate of patients treated with SBRT using the TV was 77.6% as compared to 47.5% in patients treated with the traditional CTV. Over a median follow up of 15.7 months (range: 1 to 78.2 months), 47% (N = 73 out of 155) of patients who underwent SBRT with the traditional CTV developed locoregional recurrence, but only 12% (N = 6 out of 49) treated with SBRT to the TV have thus far developed locoregional recurrence (p<0.0001). CONCLUSION In patients with localized PDAC who undergo pre-operative SBRT for BRPC/LAPC, targeting the TV may help reduce locoregional recurrence. More data and longer follow-up are needed to verify these findings and inform whether the TV may serve as a new standard for target volume delineation in this setting.
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Affiliation(s)
- S Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Lin TA, Mao S, Anker C, Herman JM, Meyer JJ, Narang A, Hu C. Local Time-to-Event Endpoint Under-Reporting and Variability in Pancreatic Cancer Trials Involving Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e316-e317. [PMID: 37785136 DOI: 10.1016/j.ijrobp.2023.06.2351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The role of radiotherapy (RT) for pancreatic adenocarcinoma (PDAC) remains controversial, with recent studies showing conflicting results. Importantly, endpoints used to evaluate efficacy in recent RT trials for PDAC have been highly variable. As variability in time-to-event (TTE) endpoint definitions is demonstrated to influence outcomes in other cancers, it is critical that radiation oncologists develop consensus around optimal endpoint definitions to use in future PDAC trial design. Thus, we conducted a systematic review of PDAC trials involving RT to characterize the frequency and variability in local TTE endpoint reporting. MATERIALS/METHODS An electronic database search was conducted of PubMed, EMBASE, and Cochrane Library to identify phase 2 and 3 clinical trials published from 2010-2022 of localized PDAC involving RT that reported any TTE endpoint (e.g., local control). After excluding duplicates, two independent reviewers screened full-text manuscripts for inclusion. Trial characteristics and local TTE endpoints/definitions were tabulated. RESULTS Three hundred twenty references were screened and 79 trials were included, of which 73 (92%) were phase 2 and 26 (33%) were randomized. Twenty (25%) trials reported a local TTE endpoint; these were local control (LC; N = 6), local progression-free survival (LPFS; N = 4), freedom from local progression (N = 6), locoregional progression-free interval (N = 1), cumulative incidence of local recurrence (N = 1), time to failure of sustained LC (N = 1), and local disease-free survival (N = 1). LC (N = 6) had 5 unique definitions and was undefined once; 1 definition included death as an event. LPFS (N = 4) had 3 definitions; 2 did not consider death an event. Among trials with local TTE endpoints, 9 trials specified the definition of a local recurrence/progression. Four trials defined local recurrence based on RT volumes; one counted clinical evidence of recurrence (e.g., tumor bleed); and one counted a rise in tumor markers without evidence of distant metastases. The index time ("time-zero") was defined for local TTE endpoints in 10 trials, including start of RT (N = 4) or chemo (N = 1), end of RT (N = 1), diagnosis (N = 1), enrollment (N = 1), and time of surgery (N = 1). CONCLUSION Few pancreatic cancer trials involving RT report local TTE endpoints, with significant heterogeneity in endpoints used and their definitions. Development of consensus endpoint definitions will be critical for future PDAC trial design.
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Affiliation(s)
- T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Anker
- The University of Vermont Medical Center, Burlington, VT
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Liu IC, Lin TA, Sehgal S, Reddy AV, Hill C, Herman JM, Meyer JJ, Narang A. Visceral Artery Pseudoaneurysm Rates after Pancreatoduodenectomy in Patients Who Received Pre-Operative Radiation for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e317. [PMID: 37785138 DOI: 10.1016/j.ijrobp.2023.06.2352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The role of pre-operative radiation therapy (RT) for localized pancreatic ductal adenocarcinoma (PDAC) with peri-pancreatic vascular involvement remains controversial, with two recent randomized controlled trials, namely PREOPANC-1 and Alliance A021501, showing conflicting results. Opponents of pre-operative radiation point towards the unclear oncologic benefit and potential added toxicity. While hemorrhage from a pseudoaneurysm (PsA) rupture is a known rare but potentially fatal complication after pancreaticoduodenectomy (PD), with published incidence rates of around 2 to 5%, it has been increasingly common in the pancreatic cancer surgical community for pre-operative RT to be cited as a risk factor for PsA development, despite the absence of data supporting this notion. Certainly, accurate characterization of relevant RT-related toxicities is critical to prevent inaccurate decision-making regarding foregoing its use. As such, we aim to report on the incidence of PsA in a cohort of patients with PDAC who underwent pre-operative RT prior to PD at a high-volume center. MATERIALS/METHODS Consecutive patients treated with pre-operative RT via stereotactic body radiation therapy (SBRT) or intensity modulated radiation therapy (IMRT) prior to PD for borderline resectable or locally advanced PDAC were retrospectively reviewed. Incidence of radiographic or clinically apparent PsA was reported. We also characterized the timing of PsA identification in relation to surgery and RT, the artery in which the PsA developed, and the clinical outcomes of patients after PsA identification. RESULTS One hundred seventy-five patients met eligibility criteria for our analysis. Most of our cohort (163 patients, 93%) received SBRT to a median dose of 6.6 Gy x 5 (median BED10 54.78 Gy, range: 48 Gy - 61.92 Gy), and only 12 patients (7%) received IMRT in various fractionation and dose patterns (median BED10 62.94 Gy, range 59.47 Gy - 97.5 Gy). The median time between surgery and last contrast-enhanced abdominal imaging was 17 months (range: 0.23 - 68 months). There were fourteen visceral arteries among thirteen patients (7%) that were found to have a PsA on routine follow-up imaging or after a post-PD hemorrhage. The median time between completion of radiation and surgery to PsA were 19.5 weeks (range: 8.6 to 98.1 weeks) and 13 weeks (range: 1.6 to 87.9 weeks), respectively. The two most commonly involved arteries were the gastroduodenal and superior mesenteric arteries. Rate of PsA development was similar among patients treated with SBRT (7%) and IMRT (8%). In terms of Clavien-Dindo classification of complications, there were six patients with grade 3a complications, five patients with grade 4b complications, and two patients with grade 5 complications. CONCLUSION Compared to historical data, pre-operative RT does not appear to significantly increase the risk of PsA development after PD. More data on the impact of pre-operative radiation dose-fraction regimen and longer follow-up are needed.
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Affiliation(s)
- I C Liu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, NY
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Tchelebi L, Korah B, Goodman KA, Hoffe S, Stricker C, Pinto DM, Deperalta D, Hong TS, Hacker-Prietz A, Narang A, Aguilera TA, Roberts H, Raldow A, Tempero M, Murphy JD, Malik NK, Herman J. Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e343-e344. [PMID: 37785197 DOI: 10.1016/j.ijrobp.2023.06.2408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC. MATERIALS/METHODS In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations. RESULTS Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation. CONCLUSION Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.
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Affiliation(s)
- L Tchelebi
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - B Korah
- 1440 Foundation Canopy Cancer Collective, Scotts Valley, CA
| | - K A Goodman
- Icahn School of Medicine at Mount Sinai, Department of Radiation Oncology, New York, NY
| | - S Hoffe
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - C Stricker
- 1440 Foundation Canopy Cancer Collective, Scotts Valley, CA
| | | | | | - T S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - H Roberts
- Dana Farber Cancer Institute, Boston, MA
| | - A Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - M Tempero
- University of California San Francisco, San Francisco, CA
| | - J D Murphy
- Department of Radiation Medicine and Applied Sciences, UC San Diego, La Jolla, CA
| | - N K Malik
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - J Herman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
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Gogineni E, Chen H, Li H, Istl AC, Johnston F, Narang A, Deville C. Comparison of Estimated Late Toxicities between IMRT and IMPT when Treating Retroperitoneal Sarcoma Preoperatively with Ultra-Hypofractionation. Int J Radiat Oncol Biol Phys 2023; 117:e298-e299. [PMID: 37785090 DOI: 10.1016/j.ijrobp.2023.06.2311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) While preoperative radiation did not improve abdominal recurrence-free survival for retroperitoneal sarcoma (RPS) in the randomized STRASS trial, it did reduce rates of local recurrence. The risk of radiation-associated toxicity is substantial, with 77% of irradiated patients experiencing grade ≥3 lymphopenia in STRASS. Thus, finding methods to mitigate the issues of delaying surgery and irradiating normal tissue may provide a path towards affording the benefits of radiation while limiting its downside. One potential solution involves the use of hypofractionation to limit delay from radiation initiation to surgery, and proton therapy to limit dose to surrounding organs at risk (OARs). We conducted a dosimetric comparison of preoperative ultra-hypofractionated intensity-modulated photon radiotherapy (IMRT) and proton therapy (IMPT) for RPS, comparing estimated rates of late toxicity using published normal tissue complication probability (NTCP) models. MATERIALS/METHODS Volumetric modulated arc therapy IMRT and IMPT plans were generated on 10 RPS patients previously treated with preoperative radiation. The prescription was 25 Gy radiobiological equivalent (GyE) to the clinical target volume (CTV) and 30 GyE to the margin-at-risk, all in five fractions. Proton doses were calculated using a radiobiological effective dose of 1.1. NTCPs were calculated for each OAR as a function of equivalent uniform dose. The ΔNTCP (difference in absolute NTCP between IMRT and IMPT plans) for each of the toxicity domains was calculated. Student T-tests were used to compare differences in dosimetric and NTCP outcomes. RESULTS CTV coverage was met for all IMRT and IMPT plans with >99% of CTVs receiving ≥100% of prescription doses. The following endpoints were significantly lower with IMPT than IMRT: mean doses to liver, bone, and all analyzed genitourinary and gastrointestinal OARs; bowel, kidney, and bone V5-V20; stomach V15; liver V5; maximum doses to stomach, spinal canal, and body; and whole-body integral dose. No OAR endpoint was significantly higher with IMPT. The average ΔNTCP for grade 3 bowel ulceration/perforation and renal toxicity was 1.9% (p = .037) and 43.0% (p = .023), respectively, favoring IMPT. Using a model-based selection threshold of any ΔNTCP >10%, 50% (n = 5) of patients would be eligible for IMPT. CONCLUSION IMPT maintained target coverage while significantly reducing dose to adjacent OARs and integral dose compared to IMRT. This translated to significantly lower risks of estimated late gastrointestinal and renal toxicities with IMPT. Further investigation is warranted to validate these findings and potential clinical benefit in the management of RPS. A prospective trial treating RPS with preoperative ultra-hypofractionated IMPT at our institution is currently being pursued (NCT05302570).
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Affiliation(s)
- E Gogineni
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - H Chen
- Provision Healthcare, Knoxville, TN
| | - H Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A C Istl
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - F Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Chen H, Gogineni E, Li H, Han-Oh S, Jia X, Deville C, Narang A. Inaugural Experience with Real-time Gated Liver Proton SBRT and Treatment Plan Quality Improvement. Int J Radiat Oncol Biol Phys 2023; 117:e286. [PMID: 37785061 DOI: 10.1016/j.ijrobp.2023.06.1274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) DIBH SBRT is routinely used for liver proton therapy. While intra-fraction target motion is limited with DIBH, acquisition of DIBH CT simulations in triplicate, as is done at our institution, reveals that variation does exist between each DIBH scan. The related target position can also vary correspondingly. The most common setup uncertainty for robust proton SBRT liver plan used at our institution is 5 mm sup-inf (SI) and 3 mm radially. Real-time gated proton therapy (RGPT) has the potential to provide instantaneous feedback for intra-fraction target motion to maximize patient safety and inform optimal treatment planning. Our first RGPT liver SBRT with intra-fraction motion under deep inspiration breath hold (DIBH). The potential treatment plan quality improvement brought by RGPT is investigated. MATERIALS/METHODS The following metrics were used in establishing our RGPT proton DIBH SBRT liver program: the iso center is always set at the fiducial mark; the beam orientation is selected to achieve both good plan quality and tracking performance; daily CBCTs are acquired and verified using fiducial maker position with kV images; robust uncertainty is determined by the gating tolerance; SBRT plan has three beams with uniform dose. Target motion was monitored throughout treatment. To evaluate dose sparing for surrounding OARs, a plan with tighter gating tolerance (3 mm SI and 2 mm radially) is optimized for dosimetric comparison. Statistical analyses were conducted using a programming environment. RESULTS Each of the three proton beams were delivered using DIBH over a total of 120-140 seconds. The average beam on time were 61.4, 66.9 and 62.8 seconds. The intra-fraction motion showed that targets could move up to 3 mm within the same DIBH. The motion increased with time. The table details the mean, maximum, standard deviation, and estimated upper 95% of directional shifts for three beams. Based on these results, plan delivery efficiency was maintained even with tighter gating tolerance. The comparison plan with tight gating tolerance showed significantly less dose (-25%) to the stomach in coronal view. CONCLUSION RGPT successfully tracked fiducial marker motion for DIBH SBRT liver treatment. Despite target drift during DIBH, the uncertainty of our DIBH SBRT procedure was sufficient to cover target motion throughout treatment. Based on the target drift value, a maximum of 25 seconds for breath hold time should be employed. Utilizing a tighter gating tolerance of 3 mm SI and 2 mm radially has the potential to maintain target coverage while significantly reducing OAR dose. Aggregated RGPT-derived data may provide optimal treatment planning parameters such as variable uncertainty based on target location.
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Affiliation(s)
- H Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E Gogineni
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - H Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - X Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Sforza D, Miles D, Villano J, Narang A, Rezaee M. Preclinical Intraoperative FLASH Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e258. [PMID: 37784991 DOI: 10.1016/j.ijrobp.2023.06.1209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Intraoperative radiation therapy (IORT) is a method of delivering high radiation doses to an internal target with low dose to adjacent organs. Most organs at risk can often be moved out of the radiation field, so dose is usually limited by in-field vascular and/or nerve structures. It is known that ultra-high (FLASH) dose rate (>40 Gy/s) radiation reduces normal tissue toxicity compared to conventional, while preserving tumor control. We hypothesize that FLASH radiation can increase the dose tolerance of vascular and nerve structures, thus permitting for dose escalation in IORT. Here, we present a novel platform using orthovoltage x-rays to study FLASH effects in preclinical IORT. The experimental setup and dosimetry of the system have been established for FLASH irradiation of the abdominal aorta in rats to investigate dose tolerance. MATERIALS/METHODS A 150 kVp rotating anode x-ray source with a 75-kW generator was used to deliver FLASH and conventional irradiation. A 3D printed immobilization platform was designed to reproducibly place a surgically exposed rat abdominal aorta at 55mm SSD. A 3-mm thick lead collimator with a 10mm x 10mm aperture was placed into a flange adapter, which docks into the immobilization platform. Phantom and in vivo dosimetry were performed using both calibrated radiographic film and thermoluminescent dosimeters (TLD). Anesthetized 2-month-old Wistar rats underwent laparotomy to expose the abdomen for irradiation. A 10x12x1 mm3 tungsten plate was placed under the aorta to reduce spinal cord dose. Animals were then docked into the irradiator using the immobilization platform. Radiation dose in the range of 20 - 50 Gy were delivered to the abdominal aorta at FLASH and conventional dose-rates. Following treatment, animals undergo MR angiography every two months for 6 months, at which a histological evaluation of aorta wall will be performed. RESULTS The FLASH dose rate measured at the aorta wall in a rat carcass was 49.7 ± 1.2 Gy/s distal to the collimator. Dose measurements between the films and TLDs showed an agreement within ±3%. Positional uncertainty mainly depends on the visual localization of the aorta on the collimator window, which is verified before irradiation. Vertical uncertainty is less than 1 mm, which is important given the rapid dose fall off of the system. Eight animals went successfully through the procedure, are healthy and currently being follow up with MR angiography. More animals are being treated for meaningful statistical results. MR angiography and IORT are performed on different days to avoid longer times under anesthesia, which initially resulted on mortality. Results of the MR angiography and histological analysis will be presented. CONCLUSION The proposed platform has been successfully utilized for precision setup for FLASH IORT in a preclinical laboratory setting. Evaluation of FLASH effects in IORT setup will be an important step in the potential translation of FLASH IORT, where only one high-dose fraction can be delivered.
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Affiliation(s)
- D Sforza
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Sibley Memorial Hospital Proton Therapy Center, Washington, DC
| | - D Miles
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - J Villano
- Department of Molecular and Comparative Pathobiology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - M Rezaee
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD
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Lin TA, Paul N, Cheung D, Saberi B, Ottman S, Gurakar A, Yarchoan M, Narang A, Kim AK, Meyer JJ. Impact of Local Therapy on Outcomes in Patients with Recurrent Hepatocellular Carcinoma after Liver Transplantation. Int J Radiat Oncol Biol Phys 2023; 117:e316. [PMID: 37785135 DOI: 10.1016/j.ijrobp.2023.06.2350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Patients with hepatocellular carcinoma (HCC) who recur after liver transplantation have limited systemic therapy options in part due to ineligibility for immune checkpoint inhibition. Thus, assessing the benefit of local, metastasis-directed therapy (MDT) is imperative. We aimed to evaluate the impact of MDT on outcomes in patients with post-transplant HCC recurrence. MATERIALS/METHODS Patients at a single center with recurrent HCC after liver transplant were identified. Recurrence/progression were assessed via RECIST criteria. At initial recurrence, patients with < = 3 metastases (mets) were considered oligorecurrent (oligoM1); those with >3 mets were polyrecurrent. Progression was defined as growth of existing mets or appearance of new mets. Poly-progression-free survival (polyPFS) was the time from oligorecurrence to polyprogression (>3 progressive mets) or death. Survival was estimated with the Kaplan-Meier method. Univariable Cox regression was used to identify covariates associated with outcomes; those with p<.05 were included in multivariable regression. RESULTS From 2005-2022, 43 patients with HCC who underwent liver transplantation experienced recurrence; 27 (63%) had oligoM1 disease at the time of recurrence. The most common sites of recurrence were liver (N = 14), abdominal nodes (N = 14), and lungs (N = 11). Low AFP (<400 ng/mL) and oligoM1 disease were associated with a favorable OS (P<.05) and these associations remained significant in multivariable analysis. Among patients with oligoM1 recurrence, 15/27 received MDT to all sites of disease (MDT-All). MDT consisted of stereotactic ablative radiotherapy (N = 6), intensity-modulated radiotherapy (N = 2), TACE (N = 1), microwave ablation (N = 3), cryoablation (N = 2), and surgery (N = 2). Among oligoM1 patients, more patients with MDT-All had liver involvement than those who did not have MDT-All (33% vs 0%, P = .047), but there was no difference in performance status, AFP, or systemic therapy receipt. Among oligoM1 patients, MDT-All was associated with improved polyPFS (median 11.7 vs 4.8 mos; P = .025), and OS (38.4 vs 16.1 mos; P = .021) compared to those who did not receive MDT-All. Two patients who received MDT-All remained alive at >4 years of follow-up from recurrence, while 1 patient remained alive at >14 years of follow-up. CONCLUSION Local therapy in patients with post-transplantation oligorecurrence (<3 mets) of HCC may delay disease progression and improve survival.
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Affiliation(s)
- T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N Paul
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D Cheung
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B Saberi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - S Ottman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Gurakar
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - M Yarchoan
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A K Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Sehgal S, Reddy A, Hill C, Lin T, Zheng L, He J, Herman J, Meyer J, Narang A. Neoadjuvant Chemotherapy and Stereotactic Body Radiation Therapy in Patients with Early Onset Pancreatic Cancer: Clinical Outcomes and Toxicity. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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13
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Gogineni E, Chen H, Narang A, Deville C. In Silico Dosimetric Comparison of Intensity-Modulated Proton Radiotherapy (IMPT) vs. Intensity-Modulated Photon Radiotherapy (IMRT) in the Preoperative Treatment of Retroperitoneal Sarcoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Reddy A, Hill C, Sehgal S, He J, Zheng L, Herman J, Meyer J, Narang A. Stereotactic Body Radiation Therapy is Safe and Feasible for the Treatment of Locally Recurrent Pancreatic Adenocarcinoma after Curative Resection. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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15
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Reddy A, Safar B, Jia A, Azad N, Christenson E, Atallah C, Efron J, Gearhart S, Zaheer A, Narang A, Meyer J. Non-Operative Management is Feasible and Safe in Patients with Rectal Cancer Who Achieve Clinical Complete Response to Short-Course Radiation Therapy and Consolidation Chemotherapy. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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16
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Lin T, Reddy A, Hill C, Sehgal S, He J, Zheng L, Herman J, Meyer J, Narang A. The Optimal Timing of Surgery Following Stereotactic Body Radiation Therapy for Borderline Resectable or Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Narang A, Shin E, Ding K, Krishnan K, Casey B, Bhutani M, Herman J, Meyer J, Hong T, Koay E. Using Hydrogel to Create Spatial Separation between the Pancreas and Duodenum in Patients with Pancreatic Cancer: A Multi-Institutional Safety and Feasibility Study. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Narang A, Hill C, Ghaly M, Korah B, Miller E, Malik N, Raldow A, Anwar M, Sanford N, Aguilera T, Kim E, Apisarnthanarax S, Murphy J, Frakes J, Hoffe S, Schefter T, Chang D, Hong T, Herman J, Goodman K. Current Practice Patterns among Radiation Oncologists at High-Volume Pancreatic Cancer Centers Participating in the Canopy Cancer Collective Learning Health Network. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Kumar R, Chouhan D, Narang A, Kalra M, Choudhary R, Kumar A. Comparative Analysis of Arthroscopic Tight Rope ACL Reconstruction Using four Strand Isolated Semitendinosus Graft and Quadrupled Combined Hamstring Graft. Arch Bone Jt Surg 2022; 10:426-431. [PMID: 35755794 PMCID: PMC9194715 DOI: 10.22038/abjs.2021.49619.2463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/31/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Arthroscopic ACL reconstruction using hamstring autograft is a quite a popular surgical procedure. But there is a conflict regarding the use of isolated semitendinosus graft or a combined hamstring graft. We did a comparative analysis of the functional outcome after ACL reconstruction performed with four strand semitendinosus graft and a combined hamstring graft over tightrope. METHODS Two groups of 30 patients each with similar demographic profiles, presenting with symptoms of instability after chronic ACL tear were included. A standard single bundle arthroscopic ACL reconstruction was performed by using four-strand semitendinosus graft in Group A and combined hamstring graft in Group B patients. Clinical and functional outcome analysis was done using quantitative anterior tibial translation measurement and Lysholm score. RESULTS The mean age of subjects in group A was 29 years and in Group B was 28 years. The semitendinosus graft length was insufficient in 13.33% cases in group A. The improvement in Lysholm score and the decrease in the tibial translation were comparable in both the groups at one year of follow-up. No added comorbidities were noted in additional removal of gracilis tendon in group B patients. CONCLUSION Isolated semitendinosus four-strand autograft can be used for arthroscopic single bundle ACL reconstruction when adequate graft length is obtained. However, one should not be hesitant in additional removal of gracilis tendon when needed. In terms of functional outcome and patient satisfaction, both the graft configurations stand the same.
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Affiliation(s)
- Ramesh Kumar
- Department of Orthopaedics, Vardhman Mahavir Medical College, New Delhi
| | - Dushyant Chouhan
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi
| | - Amit Narang
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi
| | - Mukesh Kalra
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi
| | - Ranjeet Choudhary
- Department of Orthopedics, All India Institute of Medical Sciences, Raipur
| | - Ankush Kumar
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi
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Gupta AK, Narang A, Gupta S, Kanojia RK. Bilateral Neck of Femur Fracture in a Child With Underlying Vitamin D Deficiency: A Case Report on Management and 10-Year Follow-Up. Cureus 2022; 14:e22953. [PMID: 35411281 PMCID: PMC8988905 DOI: 10.7759/cureus.22953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/05/2022] Open
Abstract
Bilateral femoral neck fracture is a rare entity in the pediatric age group. These types of fractures occur mostly due to high-velocity trauma. We report the surgical outcome with approximately 10 years of follow-up in a 10-year-old child presenting with bilateral femoral neck fracture after trivial trauma and underlying nutritional vitamin D deficiency. A 10-year-old female child with bilateral neglected fracture neck of femur was managed with a primary valgus osteotomy done on the left side and closed reduction and screw fixation with fibular grafting done on the right side. Later on, as the right side fracture progressed to non-union, it was converted to valgus osteotomy fixed with an external fixator. The patient had a good functional outcome at 10 years of follow-up with no difficulty in her day-to-day activities. Pathological bilateral fracture neck of femur is rare in children and it is often mismanaged due to a delayed diagnosis. It can have potentially dangerous complications with a grave outcome affecting the rest of the life of the child. Hence it is important to know about such rare presentations so that they can be adequately addressed early on, thereby minimizing the risk of complications like non-union and avascular necrosis.
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Narang A, Aggarwal V, Jain R, Maheshwari C, Ramesh A, Singh G. Nasoethmoidal Schwannoma as a Mimicar of Esthesioneuroblastoma: A Case Report and Literature Review. Neurol India 2022; 70:784-787. [PMID: 35532661 DOI: 10.4103/0028-3886.344679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Nasoethmoidal schwannomas are rare lesions and their presentation with intracranial extension is even rarer. Here, a patient presenting with rhinorrhea, epistaxis, and proptosis of left eye was diagnosed with giant nasoethmoidal schwannoma extending to frontal lobe and orbit, which was managed with bifrontal craniotomy with endoscopic transnasal gross total excision. This being predominantly a benign lesion has good prognosis if total excision is achieved.
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Affiliation(s)
- Amit Narang
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Varun Aggarwal
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Rahul Jain
- Department of General Surgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Chandni Maheshwari
- Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Athira Ramesh
- Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Gurbax Singh
- Department of Otorhinolaryngology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Reddy A, Hill C, Sehgal S, Ding D, Zheng L, He J, Herman J, Meyer J, Narang A. KRAS and NOTCH1/2 Mutations are Associated With Pathologic and Clinical Outcomes in Localized Pancreatic Cancer Treated With Neoadjuvant Chemotherapy and Stereotactic Body Radiotherapy Followed by Surgical Exploration. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hill C, Fellows A, Hobbs R, Reddy A, Herman J, Meyer J, Narang A. Proposed Model of Dose Escalation in Localized Pancreatic Cancer Patients Eligible for Surgical Exploration: Neoadjuvant Intensity Modulated Radiation Therapy (IMRT) vs. Stereotactic Body Radiation Therapy (SBRT) and Intra-Operative Radiotherapy (IORT). Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hill C, Sehgal S, Reddy A, Herman J, Meyer J, Narang A. What Should We Cover Beyond Gross Disease With Radiation Therapy for Localized Pancreatic Ductal Adenocarcinoma (PDAC): Proposal of an Innovative and Standardized Clinical Tumor Volume (CTV) for PDAC of the Head – The Triangle. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Aggarwal V, Narang A, Jain R, Maheshwari C, Kavita D. Surgical Nuances of Intramedullary White Epidermoid Cyst in the Conus Medullaris: A Rare Entity. Asian J Neurosurg 2021; 16:614-617. [PMID: 34660381 PMCID: PMC8477828 DOI: 10.4103/ajns.ajns_321_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
Spinal epidermoid cysts (ECs) are benign slow-growing spinal tumors. The account for <1% of spinal tumors and are usually found intradural extramedullary. This report is regarding two rare cases of intramedullary white ECs present at the conus medullaris. In the first case, a 32-year-old male presented with a complaint of lower backache for 5 years, which progressively increased in intensity, radiating to the left leg. The patient had left lower limb weakness in the form of difficulty in walking. On examination, power of left knee and ankle was 4/5. Left extensor hallucis longus power was 3/5. Left Babinski sign was extensor. In the second case, a 42-year-old male, presented with a complaint of numbness over the left foot for 5–6 months. On examination, the power of the left ankle was 3/5, left extensor hallucis longus was 3/5. Both patients had EC in conus medullaris, which was hyperintense on T1-weighted magnetic resonance imaging and underwent laminectomy with the evacuation of the cyst with electrocoagulation of cyst epithelial lining. White ECs are extremely rare in the conus medullaris. Electrocoagulation of the cyst wall is like walking on a tight rope. Liberal electrocoagulation can lead to the neurological deficit but decreases the chances of recurrence. On the other hand, conservative electrocoagulation can lead to recurrence but decreases the chance of a new deficit. Recurrence should also lead to suspicion of atypical changes in the cyst wall, which may require adjuvant treatment such as radiotherapy and chemotherapy.
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Affiliation(s)
- Varun Aggarwal
- Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Amit Narang
- Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Rahul Jain
- Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Chandni Maheshwari
- Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Divya Kavita
- Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
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Narang A, Chattopadhyay A, Sharma A, Gupta S. Treatment of Cleft Foot Deformity using Fish Mouth Incision and Suture-Button in Paediatric Foot. Sultan Qaboos Univ Med J 2021; 22:288-290. [PMID: 35673300 PMCID: PMC9155040 DOI: 10.18295/squmj.8.2021.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/18/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Cleft foot is a congenital anomaly characterized by absence of the metatarsal bones and phalanges. It is commonly seen in children with Ectrodactyly-ectrodermal dysplasia and clefting syndrome (EEC) ranging from a median cleft up to the mid metatarsals to a deep cleft up to the tarsal bones. Surgical treatment in the form of cleft closure, excision of the rudimentary metatarsal bone and cross K-wire fixation of metatarsal bones have been tried for the management of such cases. Here, we report a case of one year old child with Type III cleft foot having four metatarsals, who was treated with suture-endobutton system using three transverse tunnels in the 2nd and 3rd metatarsal bones in order to bring them closer. We were able to achieve a satisfactory outcome with a normal fitting shoe wear.
Keywords: Cleft foot; suture-button; fish mouth incision.
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Rawat S, Sharma PK, Narang A. How COVID (Pandemics) Impacted Training of Medical Students, Trainees, and Residents? J Coll Physicians Surg Pak 2021; 31:147-148. [PMID: 34271823 DOI: 10.29271/jcpsp.2021.supp2.s147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/23/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Seema Rawat
- Department of Gynecology and Obstetrics, UCMS, Govt Medical Collage, New Delhi, India
| | - Pankaj Kumar Sharma
- Department of Orthopedics, All India Institute of Medical Sciences, Bathinda, India
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Basantani N, Narang A, Basantani K, Tyagi G. Successful operative management of giant anterior sacral meningocele via trans-abdominal approach in an adult male. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2020.101077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kumar A, Passey J, Chouhan D, Saini M, Narang A. CT Based Characterization of Volar Surface of Distal Radius: Can an Ideal Volar Plate for Fixation of Distal Radial Fractures be Designed? J Hand Surg Asian Pac Vol 2021; 26:77-83. [PMID: 33559579 DOI: 10.1142/s2424835521500120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Literature has limited evidence concerning the morphology of volar surface of distal radius. A mismatch between the plate-contour and contour of the actual volar bony surface can result in malreduction. The purpose of this study is to analyze the normal curvature morphology of volar surface of distal radius and related parameters that can help in designing of the volar plates for fixation of distal radial fractures. Methods: We retrospectively analyzed CT scans of uninjured healthy distal radii performed during a one year period (2018-2019). The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, the mediolateral surface angle between intermediate column and radial column of distal radius, the curvatures and locations of their vertices for radial and intermediate columns were measured. Results: A total of 84 CT-based studies were analyzed. The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, and the mediolateral surface angle between intermediate column and radial column of the distal radius were 24.27 mm, 144.8 degrees and 163.1 degrees, respectively. The mean volar curvatures of the radial and intermediate columns were 156.5 and 151.4 degrees, respectively and distances of their vertices from the pronator-quadratus line were 10.96 mm and 14.13 mm, respectively. Conclusions: Considerable variations occur in curvature morphology of distal radial volar surface. A best fit rather than an anatomical fit can be considered during implant selection owing to these variations. Besides volar curvature of radial and ulnar columns, location of their vertices, mediolateral angulation and surface curvature between these columns at the level of watershed line should also be considered in plate selection. A combination of a few serial increments of the described parameters in the designs of volar fixation plates would be helpful for surgeons in the best implant selection.
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Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Jigyasa Passey
- Department of Anatomy, Maulana Azad Medical College, New Delhi, India
| | - Dushyant Chouhan
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Manish Saini
- Department of Orthopaedics, Shalby Hospital, Surat, Gujarat, India
| | - Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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Singh P, Aggarwal V, Narang A, Maheshwari C. Acute subdural hematoma after spinal surgery. Vasc Invest Ther 2021. [DOI: 10.4103/vit.vit_24_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sharma A, Sinha S, Gupta S, Gupta A, Narang A, Sharma P, Kanojia RK. Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length. Strategies Trauma Limb Reconstr 2021; 16:20-26. [PMID: 34326898 PMCID: PMC8311751 DOI: 10.5005/jp-journals-10080-1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective To assess the use of arm length (AL) for the estimation of tibial nail length preoperatively and compare its accuracy to various established upper and lower limb anthropometric parameters. Material and methods This prospective study of 54 patients assessed upper limb parameters as a possible alternative for intraoperatively measured tibial nail length. The anthropometric parameters measured independently by two observers were AL, olecranon to fifth metacarpal head (OMD), tibial tuberosity to medial malleolus (TT-MM), tibial tuberosity to medial malleolus minus 20 mm (TT-MM-20 mm) and knee joint line to medial malleolus minus 40 mm (KJL-MM-40) and compared to final nail size used intraoperatively. Two observers were used. Bland-Altman plots were constructed to assess the limits of agreement to intraoperative estimates of optimum nail length. A repeatability assessment was also assessed by both observers. Results None of the anthropometric parameters showed limits of agreement within ±10 mm of nail length. AL showed the least average difference and best limits of agreement among all the anthropometric parameters. Among the lower limb parameters, the KJL-MM showed the least average difference but poorer limits of agreement to nail length. The OMD measurement showed a greater average difference than the AL indicating it is a poorer upper limb parameter for predicting nail length. Conclusion AL as measured between the angle of the acromion to the lateral epicondyle can be used as a preoperative upper limb anthropometric estimate of nail length to one nail size of the optimum length. Further studies with a larger sample size may reduce the confidence intervals and help justify its wider use. How to cite this article Sharma A, Sinha S, Gupta S, et al. Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length. Strategies Trauma Limb Reconstr 2021;16(1):20–26.
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Affiliation(s)
- Amit Sharma
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Siddhartha Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Sumit Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Anand Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Parul Sharma
- Department of Orthopaedics, Jamia Milia Islamia University, New Delhi, India
| | - Rajesh K Kanojia
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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Narang A, Chan G, Aframian A, Ali Z, Carr A, Goodier H, Morgan C, Park C, Sugand K, Walton T, Wilson M, Belgaumkar A, Gallagher K, Ghosh K, Gibbons C, Keightley A, Nawaz Z, Wakeling C, Sarraf K, Rogers BA, Kieffer WKM. Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study. Int Orthop 2021. [PMID: 32862265 DOI: 10.1007/s00264-020-04739-y/figures/2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
PURPOSE Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.
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Affiliation(s)
- A Narang
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - G Chan
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - A Aframian
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Z Ali
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - A Carr
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - H Goodier
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - C Morgan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - C Park
- St Mary's Hospital, London, London, UK
| | - K Sugand
- St Mary's Hospital, London, London, UK
| | - T Walton
- Brighton and Sussex University Hospitals, Brighton, UK
| | - M Wilson
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - A Belgaumkar
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - K Gallagher
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - K Ghosh
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - C Gibbons
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - A Keightley
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Z Nawaz
- Frimley Park Hospital, Camberley, UK
| | - C Wakeling
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - K Sarraf
- St Mary's Hospital, London, London, UK
| | - B A Rogers
- Brighton and Sussex University Hospitals, Brighton, UK
| | - W K M Kieffer
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK.
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Affiliation(s)
- S Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - S Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - A Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - R K Kanojia
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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Surette S, Narang A, Bae R, Hong H, Thomas Y, Cadieu C, Chaudhry A, Martin R, Rubenson D, Goldstein S, Little S, Lang R, Weissman N, Thomas J. Artificial intelligence-guided image acquisition on patients with implanted electrophysiological devices: results from a pivotal prospective multi-center clinical trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
A novel, recently FDA-authorized software uses deep learning (DL) to provide prescriptive transthoracic echocardiography (TTE) guidance, allowing novices to acquire standard TTE views. The DL model was trained by >5,000,000 observations of the impact of probe motion on image orientation/quality. This study evaluated whether novice-acquired TTE images guided by this software were of diagnostic quality in patients with and without implanted electrophysiological (EP) devices, focusing on RV size and function, which were thought to be sensitive to EP devices. Some aspects of the study have previously been presented.
Methods
240 patients (61±16 years old, 58% male, 33% BMI >30 kg/m2, 91% with cardiac pathology) were recruited. 8 nurses without echo experience each acquired 10 view TTEs in 30 patients guided by the software. 235 of the patients were also scanned by a trained sonographer without assistance from the software. 5 Level 3 echocardiographers independently assessed the diagnostic quality of the TTEs acquired by the nurses and sonographers to evaluate the effect of EP devices on DL software performance.
Results
Nurses using the AI-guided acquisition software acquired TTEs of sufficient quality to make qualitative assessments of right ventricular (RV) size and function in greater than 80% of cases for patients with and without implanted EP devices (Table). There was no significant difference between nurse- and sonographer-acquired scans.
Conclusion
These results indicate that new DL software can guide novices to obtain TTEs that enable qualitative assessment of RV size even in the presence of implanted EP devices. The results of the comparison to sonographer-acquired exams indicate the software performance is robust to presence of pacemaker/ICD leads visible in the images (Figure).
Nurse-acquired TTE with visible ICD lead
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Caption Health, Inc.
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Affiliation(s)
- S Surette
- Caption Health, Brisbane, United States of America
| | - A Narang
- Northwestern University, Chicago, United States of America
| | - R Bae
- Minneapolis Heart Institute Foundation, Minneapolis, United States of America
| | - H Hong
- Caption Health, Brisbane, United States of America
| | - Y Thomas
- Caption Health, Brisbane, United States of America
| | - C Cadieu
- Caption Health, Brisbane, United States of America
| | - A Chaudhry
- Caption Health, Brisbane, United States of America
| | - R Martin
- Caption Health, Brisbane, United States of America
| | - D Rubenson
- Scripps Clinic, La Jolla, United States of America
| | - S Goldstein
- MedStar Washington Hospital Center, Washington, United States of America
| | - S Little
- Houston Methodist, Houston, United States of America
| | - R Lang
- The University of Chicago, Chicago, United States of America
| | - N Weissman
- MedStar Health Research Institute, Washington, United States of America
| | - J.D Thomas
- Northwestern University, Chicago, United States of America
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Chen H, Meyer J, Narang A, Han-Oh S, Ding K, Wong J, Tsien C, Li H. Delivery Uncertainty Estimation Using Daily Breath-Hold Cone-Beam CTs For Liver Proton Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Han-Oh S, Hill C, Wang K, Ding K, Li H, Chen H, Meyer J, Narang A. Dosimetric Impact of Deep Inspiration Breath Hold Uncertainty on Pancreas Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Miccio J, Mokhtech M, Jabbour S, Anker C, Patel T, Park H, Cecchini M, Salem R, Kuntsman J, Stein S, Kortmansky J, Lacy J, Narang A, Herman J, Haddock M, Hallemeier C, Johung K, Jethwa K. Association of Neoadjuvant Treatment Modality with Negative Margin and Pathologic Downstaging in Patients Undergoing Pancreatic Cancer Resection: A National Cancer Database Analysis. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF STUDY Planovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters. METHODS 17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance. RESULTS Improvement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis. CONCLUSION Calcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.
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Kumar A, Chouhan D, Narang A, Khan R, Mittal S. "Clamp and plate" - A simple technique for prevention of varus malreduction in reverse oblique peritrochanteric fractures. J Clin Orthop Trauma 2020; 11:S667-S670. [PMID: 32774047 PMCID: PMC7394818 DOI: 10.1016/j.jcot.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/27/2022] Open
Abstract
Reverse oblique peritrochanteric fractures are unstable injuries. They have an inherent tendency of lateral wall opening and varus displacement. Cephalomedullary nails are the preferred implants for fixation of these fractures. Standard techniques and a medial entry point may not always be helpful in correcting alignment, resulting in persisting varus malreduction. A simple technique using a Lowman clamp and a conventional 3.5 mm plate has been described to prevent lateral wall opening and indirectly, the varus malreduction.
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Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, 110062, India
| | - Dushyant Chouhan
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi, India
| | - Amit Narang
- Department of Orthopedics, Lady Hardinge Medical College, New Delhi, India
| | - Rizwan Khan
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, 110062, India
| | - Samarth Mittal
- JPN Apex Trauma Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India,Corresponding author. JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Aggarwal V, Maheshwari C, Kavita D, Narang A. Experience, challenges and lessons learnt from microsurgical clipping of intracranial aneurysms at an emerging neurosurgical centre. roneuro 2020. [DOI: 10.33962/roneuro-2020-038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives: To share our experience, challenges faced, lessons learnt and analyze the results of surgical management by microsurgical clipping of intracranial aneurysms at an emerging neurosurgical centre at Guru Gobind Singh medical college and hospital (GGSMC&H) Faridkot, Punjab. India.
Material and Methods: This study includes all the patients who presented with the diagnosis of intracranial aneurysm on CT angiography and were treated with the microsurgical clipping, between March 2017 to April 2019.
Results: There was a total of 23 patients 11female and 12 male. Age range 32 to 85years. On admission 22 patients had SAH on CT scan and one was admitted after incidental detection of the aneurysm without SAH. The time interval between ictus and admission was 0-3 days in 13 patients, 3-14 days in 8 patients and more than 14 days in 1 patient. WFNS grade (gd) I-15 patients, gd II-2, gd III-2, gd IV-3 patients. Fisher gd I-nil, gd II-9, gd III-4, gd IV-9 patients. In 23 patients 27 Aneurysms were clipped. Distribution of location was Anterior Communicating-12, Distal Anterior Cerebral Artery- 4, Middle cerebral artery (MCA) Bifurcation-3, MCA trifurcation-1, Anterior Choroidal-1, Posterior Communicating (P-com) -1, Ophthalmic Internal Carotid Artery (OICA)-4 and three patients had associated multiple aneurysms. Size of aneurysms varied from < 02mm diameter in 2 patients, 2-25mm - 23 and, more than 25mm-2 aneurysms. There was intra op rupture in 2 cases. Post-operatively 2 patients developed hemiparesis, which recovered, nine patients developed vasospasm. Two patients developed chest related complications. One patient developed renal failure. There were 8 deaths. Patients are on follow up since March 2017 till date.
Conclusions: Intracranial aneurysms are challenging to manage due to their proximity to vital intracranial structures, and difficulty in securing intracranial proximal control. Thorough knowledge of intracranial anatomy of adjacent relations, arachnoid planes and skilful dissection is a key element for a successful outcome. Data collected from GGSMC & Hospital may not be representative of the entire state or country’s population. Therefore, a large-scale data collection is necessary to create our own database to ascertain the risk factors and preventive measures that are exclusive to our state and nation.
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Chouhan D, Meena S, Kamboj K, Meena MK, Narang A, Sinha S. Distal Locked versus Unlocked Intramedullary Nailing in Intertrochanteric Fracture; A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Trials. Bull Emerg Trauma 2020; 8:56-61. [PMID: 32420389 PMCID: PMC7211383 DOI: 10.30476/beat.2020.46444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials. Methods: Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis. Results: The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08). Conclusion: The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Dushyant Chouhan
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
| | - Sanjay Meena
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
| | - Kulbhushan Kamboj
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
| | - Mukesh Kumar Meena
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
| | - Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
| | - Siddhartha Sinha
- Department of Orthopaedics, Lady Hardinge Medical college and associated hospitals, New Delhi, India
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Narang A, Singh Randhawa S, Kumar Sood N, Chhabra S, Singla LD, Kaur P. Atypical theileriosis with cutaneous involvement in a cow in India: a case report. REV SCI TECH OIE 2020; 38:703-709. [PMID: 32286574 DOI: 10.20506/rst.38.3.3019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bovine tropical theileriosis caused by Theileria annulata is an overwhelming haemoprotozoan tick-borne disease in taurine and cross-bred cattle in Punjab, India. However, there seems to be no report from India of cutaneous nodules associated with the disease. This report describes a five-year-old cross-bred cow presented to a university clinic with a history of fever, inappetence and malaise for the past six to seven days. Clinical examination revealed normal vital parameters, pale mucous membranes, mild enlargement of the prescapular lymph nodes and multiple subcutaneous nodular masses (2-4 cm) on the neck and abdomen. Haematology revealed mild anaemia and leucopenia with 48% neutrophils, 48% lymphocytes and 4% eosinophils. Romanowsky-stained smears of fineneedle aspiration biopsy samples from swollen lymph nodes and subcutaneous masses showed an increased number of lymphoid cells, suggesting cutaneous lymphomatosis. However, a critical examination of the smears from subcutaneous nodules showed a large number of Koch's blue bodies in macrophages and lymphoblasts, and several piroplasms were also noticed within the red blood cells in lymph node smears. A peripheral blood smear revealed mild to moderate parasitaemia. Extracted DNA from the parasitologically positive blood sample was subjected to nested polymerase chain reaction (nPCR) using T. annulata speciesspecific primers encoding the 30-kiloDalton major sporozoite surface antigen. The desired 572-base pair amplified product of the nPCR was comparable to the positive control. This seems to be a rare case of T. annulata in an adult cross-bred cow, showing cutaneous nodular involvement.
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Sharma A, Sinha S, Narang A, Chouhan DK, Gupta S. Waddling Gait: A complication of valproate therapy and a thought beyond vitamin D deficiency. Sultan Qaboos Univ Med J 2020; 20:e104-e108. [PMID: 32190378 PMCID: PMC7065696 DOI: 10.18295/squmj.2020.20.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/02/2019] [Accepted: 11/14/2019] [Indexed: 12/02/2022] Open
Abstract
Proximal muscle weakness is a common presentation in paediatric-orthopaedic clinics and is frequently paired with a vitamin D deficiency diagnosis. Recently, side effects of the extensive use of antiepileptic and antipsychotic drugs such as sodium valproate in childhood disorders are being documented. Sodium valproate causes a time-dependent, drug-induced proximal myopathy. We report a 13-year-old female patient who presented at the Orthopaedic Outpatient Department at Lady Hardinge Medical College, New Delhi, India, in 2019 with an abnormal gait. The patient was taking a combination therapy of sodium valproate, risperidone and trihexyphenidyl for absence seizures and a mood disorder. Following clinical investigations, the patient was diagnosed with proximal myopathy. As a result of elevated serum alkaline phosphatase and creatine kinase myocardial band levels, sodium valproate was replaced with ethosuximide and a carnitine supplementation was prescribed. The patient fully recovered and regained full mobility. Proximal myopathy had been incorrectly managed and assumed to be caused by a vitamin D deficiency.
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Affiliation(s)
- Amit Sharma
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Siddhartha Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Dushyant K Chouhan
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Sumit Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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Kumar A, Narang A, Chouhan D, Passey J. Letter to editor concerning "Patella fractures treated with cannulated lag screws and FiberWire® have a high union rate and low rate of implant removal " by Busel, Gennadiy et al. injury, 2019 (in press). Injury 2020; 51:574. [PMID: 31757467 DOI: 10.1016/j.injury.2019.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/09/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, HIMSR, New Delhi 110062, India.
| | - Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Dushyant Chouhan
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Jigyasa Passey
- Department of Anatomy, Maulana Azad Medical college, New Delhi 110062, India
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Singh P, Aggarwal V, Narang A, Maheshwari C. Bilateral medulloblastoma. Vasc Invest Ther 2020. [DOI: 10.4103/vit.vit_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Singh P, Aggarwal V, Narang A, Maheshwari C. Primary bilateral thalamic glioma with bipeduncle involvement of midbrain. Vasc Invest Ther 2020. [DOI: 10.4103/vit.vit_22_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pearlman AS, Narang A, Hong H, Hsieh C, Chaudhry A, Chen C, Guttas S, Surette S, Parajuli N, Polivert N, Cadieu C, Martin RP, Thomas JD, Weissman NJ. 547 Point-of-care cardiac assessment using machine learning to guide image acquisition. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Bay Labs, Inc; San Francisco, CA
Background/Introduction: When used by experienced examiners, the utility of point-of-care (POC) ultrasound for assessing cardiac anatomy and function has been well established. However, in some clinical circumstances (Primary Care offices, Intensive Care Unit, some Emergency Rooms, or in remote settings) in which a rapid assessment of cardiac anatomy and dynamics can facilitate patient care, an examiner experienced at POC scanning may not be immediately available.
Purpose
To help novice users acquire clinically useful standard cardiac views using novel machine learning (ML) software.
Methods
We used an investigational device that employs ML software to provide real-time adaptive guidance of transducer position and orientation to help novice users acquire tomographic views of the heart. We tested the utility of this approach when 4 nurses with no prior training in sonography performed POC studies on 16 subjects (10 healthy, 6 with cardiac abnormalities; 9 men; body mass index normal in 6, overweight in 6, and obese in 4 subjects). Each nurse underwent didactic training and 4 hours of supervised practice using the ML program. Each nurse scanned each study subject using a scanner equipped with ML software to acquire 10 digital two-dimensional image clips, including: parasternal long axis, short axis at the aortic valve, mitral valve, and mid-left ventricle (LV), apical 2-, 4-, and 5-chamber, subcostal 4-chamber, and longitudinal views of the inferior vena cava (IVC). All video clips (n = 640) were later reviewed independently by 5 level 3-trained cardiologists who were blinded to subject, scanner, and each other"s assessments. The expert readers reviewed each set of 10 clips to determine if the following variables could be assessed qualitatively: LV size and function; right ventricular (RV) size and function; aortic, mitral and tricuspid valves; pericardial effusion; left atrial size; IVC size.
Results
The majority of expert readers concurred, independently, that the sets of images acquired by nurses using ML guidance allowed qualitative assessment of LV size and function in 98%, pericardial effusion in 98%, RV size and function in 92%, and aortic and mitral valve anatomy and dynamics in 94-97% of cases. Qualitative assessment of LA size was feasible in 95%. Images of the IVC were judged as adequate for assessment in 58%.
Conclusion
This preliminary study suggests the potential value of novel ML software by demonstrating that nurses with limited training can acquire tomographic images useful for qualitative assessment of the cardiac chambers and valves in more than 90% of the subjects examined. This approach might be useful when timely POC cardiac assessment is indicated in settings where an experienced examiner is not available. Further refinements in the guiding software are needed to improve the success rate of IVC imaging, since IVC size can be a useful indicator of volume status.
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Affiliation(s)
- A S Pearlman
- University of Washington, Seattle, United States of America
| | - A Narang
- Northwestern University, Chicago, United States of America
| | - H Hong
- Bay Labs, Inc, San Francisco, United States of America
| | - C Hsieh
- Bay Labs, Inc, San Francisco, United States of America
| | - A Chaudhry
- Bay Labs, Inc, San Francisco, United States of America
| | - C Chen
- Bay Labs, Inc, San Francisco, United States of America
| | - S Guttas
- Bay Labs, Inc, San Francisco, United States of America
| | - S Surette
- Bay Labs, Inc, San Francisco, United States of America
| | - N Parajuli
- Bay Labs, Inc, San Francisco, United States of America
| | - N Polivert
- Bay Labs, Inc, San Francisco, United States of America
| | - C Cadieu
- Bay Labs, Inc, San Francisco, United States of America
| | - R P Martin
- Bay Labs, Inc, San Francisco, United States of America
| | - J D Thomas
- Northwestern University, Chicago, United States of America
| | - N J Weissman
- Medstar Research Institute, Washington, DC, United States of America
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Slathia P, Narang D, Chandra M, Sharma A, Narang A. Detection of non-tuberculous mycobacterial species using PCR-RFLP analysis in trans-tracheal washes in cattle and buffaloes with respiratory distress. Iran J Vet Res 2020; 21:136-140. [PMID: 32849894 PMCID: PMC7430363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Bovine tuberculosis (bTB) is a chronic disease of cattle with high economic importance in livestock farming caused by Mycobacterium bovis and bears a zoonotic potential. There are some non-tuberculous mycobacteria (NTM) which cause disease similar to bTB and interfere with diagnosis of bTB. Non-tuberculous mycobacteria are saprophytic in nature but some of them may cause pulmonary infections, mastitis, lesions in respiratory tract and lymph nodes of cattle, due to which they are being recognized worldwide and interfere with the diagnosis of bTB. AIMS The aim of the study was to detect NTM species from cattle and buffaloes with respiratory distress using biochemical test and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis (PRA). METHODS A total of 50 trans-tracheal washes were collected from cattle (n=41) and buffaloes (n=9) with respiratory distress. The samples were inoculated on Middlebrook 7H10 media after proper decontamination with 4% NaOH. The isolate obtained was identified by biochemical testing. Extracted DNA from samples and isolate was subjected to PRA which involved hsp65 gene amplification (439 bp) and RFLP analysis of amplified product. RESULTS Out of 50 trans-tracheal washes only one isolate of Mycobacterium kansasii (n=1) (2%) was obtained which was confirmed by biochemical testing and PRA. Mycobacterium kansasii (n=4) (8%), Mycobacterium intracellulare (n=1) (2%), and Mycobacterium vaccae (n=1) (2%) were identified by PRA. CONCLUSION The study emphasizes the importance of NTM in animals. Polymerase chain reaction-restriction fragment length polymorphism analysis is a more reliable and rapid method for identification of NTM than conventional methods.
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Affiliation(s)
- P. Slathia
- Ph.D. Student in Veterinary Microbiology, Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - D. Narang
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - M. Chandra
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - A. Sharma
- Department of Veterinary Medicine, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - A. Narang
- Department of Veterinary Medicine, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
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Narang A, Maheshwari C, Aggarwal V, Bansal P, Singh P. Gorlin-Goltz Syndrome with Intracranial Meningioma: Case Report and Review of Literature. World Neurosurg 2019; 133:324-330. [PMID: 31605858 DOI: 10.1016/j.wneu.2019.09.156] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Gorlin-Goltz syndrome is a rare hereditary disease affecting multiple organ systems. Medulloblastoma is the most common intracranial malignancy in these patients, radiotherapy makes them more susceptible to intracranial meningioma. Here we report an intracranial meningioma without radiation exposure. CASE DESCRIPTION We present a case of intracranial meningioma in a young woman who was postoperatively diagnosed to have Gorlin-Goltz syndrome based on presence of calcification of bilateral tent and falx. Further clinical and radiological assessment helped us identify many other syndromic features and patient was promptly advised multispecialty consultations to screen for other malignancies and counselled regarding risk factors. CONCLUSIONS Early identification of the syndrome is important for prevention of secondary radiation-induced malignancies, both intracranial and extracranial. Patients need multidisciplinary approach for management.
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Affiliation(s)
- Amit Narang
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Chandni Maheshwari
- Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Varun Aggarwal
- Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India.
| | - Puneet Bansal
- Department of Surgery, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Paramdeep Singh
- Deparment of Radiology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Narang A, Gupta S, Kanojia RK, Sinha S. An unusual Pattern of Flexor Digitorum Profundus Avulsion Injury with a Large Extra-articular Bony Fragment. J Orthop Case Rep 2019; 9:65-67. [PMID: 31559231 PMCID: PMC6742862 DOI: 10.13107/jocr.2250-0685.1424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Avulsion injury of the flexor digitorum profundus (FDP) tendon, commonly known as jersey finger, is seen in contact sports players such as rugby and football. There are mainly three patterns of this type of injury as mentioned in the Leddy and Packer classification on the basis of the level of retraction of the tendon. Subsequently, a Type IV injury was added by Smith, where the tendon was also separated from the avulsed bony fragment. It is the level of tendon retraction and the status of the long and the short vincula post-injury that determines the outcome of repair in these types of injuries. Case Report: Here, we report an unusual case of jersey finger injury in a 45-year-old male patient, where the FDP tendon was found in front of the middle phalanx with a large, fractured fragment of the middle third of the distal phalanx attached to it. This type of injury pattern has not been acknowledged in the commonly used classification systems. The patient was operated with open reduction and K-wire fixation of the bony fragment with a good functional outcome. Conclusion: While treating the cases of jersey finger injuries in sports players and general population, one should be aware of such rare patterns which can then be easily managed with proper pre-operative planning.
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Affiliation(s)
- Amit Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Sumit Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | | | - Siddhartha Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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