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July-September 2019
Volume 15 | Issue 3
Page Nos. 449-739

Online since Wednesday, May 29, 2019

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REVIEW ARTICLES  

A comprehensive review of surgical margin in oral squamous cell carcinoma highlighting the significance of tumor-free surgical margins Highly accessed article p. 449
Mamata Kamat, Bhagawan Das Rai, Rudrayya S Puranik, Uma Vasant Datar
DOI:10.4103/jcrt.JCRT_273_17  PMID:31169203
Oral squamous cell carcinoma (OSCC) is the most common malignancy of the oral cavity, and surgery is the most accepted line of treatment. The surgical margins (SMs) or resection margins are boundaries of resection specimen excised by the surgeon. The status of these resected SMs is an important and valuable tool to predict the treatment outcome. It is necessary to attain optimal SM to avoid local recurrence and improve overall survival. However, the controversies exist regarding the concept of optimal SM. There are various factors that influence the assessment of the SMs. In addition, apart from routine histopathology, the molecular assessment of resected margins has recently gained value which has a promising role for margin surveillance. Furthermore, the histological and molecular appraisal of tumor-free margins is also necessary to standardize the treatment modalities. Hence, this review aims to summarize the above issues that influence the evaluation of SMs of OSCC along with recent updates. Furthermore, an attempt has been made to give an overview about future possible approaches for the tumor-free margins. An electronic search was performed for items related to the evaluation of SMs in OSCC, and the obtained articles were critically assessed and the relevant information was extracted and summarized.
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Molecular characterization of metastasizing ameloblastoma: A comprehensive review p. 455
Anjali P Ganjre, Gargi Sarode, Sachin Sarode
DOI:10.4103/jcrt.JCRT_268_17  PMID:31169204
Metastasizing ameloblastoma (MA) is a very rare odontogenic tumor with 2% of incidence rate. It exhibits benign histopathological features and malignant intrinsic quality in the form of metastasis which makes it a little more than a pathological curiosity. Various molecular aspects related with malignant behavior have been discussed. Because of this, it provides a diagnostic challenge for clinicians and surgeons. It is an elusive lesion which should be more researched and studied so that definitive diagnostic features can be put forward. The objective of this paper is to review the molecular aspect involved in the pathogenesis of MA which will aid in differentiating non-MA from MA and thus helping in providing proper treatment at an early stage.
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Oral submucous fibrosis: An enigmatic morpho-insight p. 463
Alka Harish Hande, Minal S Chaudhary, Madhuri N Gawande, Amol R Gadbail, Prajakta R Zade, Shree Bajaj, Swati K Patil, Satyajit Tekade
DOI:10.4103/jcrt.JCRT_522_17  PMID:31169205
Oral submucous fibrosis (OSMF) is a chronic progressive, scarring disease affecting oral, oropharyngeal, and sometimes the esophageal mucosa. It is characterized by the progressive fibrosis of the submucosal tissue. The pathogenesis of OSMF has been directly related to the habit of chewing areca nut and its commercial preparation, which is widespread in Indian subcontinent and Southeast Asia. The areca nut has been classified as a “group one human carcinogen.” Oral squamous cell carcinoma in the background of OSMF is one of the most common malignancies in South and Southeast Asian countries. Malignant transformation has been reported in 7%–12% cases of OSMF. Histopathological spectrum of OSMF includes the apparent alterations observed in the epithelium and connective tissue. Epithelial atrophy and sometimes epithelial hyperplasia with or without dysplasia are the peculiar alterations seen in the epithelium. In the connective tissue, there is extracellular matrix remodeling which results in excessive collagenization. Further cross-linking of collagen leads to hyalinization which makes the collagen resistant to proteolysis. Owing to fibrosis in the connective tissue, there is narrowing of blood vessels which further results in compromised blood supply to the local tissue milieu, that is, hypoxia. This tissue hypoxia elicits angiogenesis which may result in the malignant transformation of OSMF. Perpetual irritation of areca nut and its constituents to the oral mucosa leads to upregulation of pro-inflammatory cytokines and further juxtaepithelial inflammation. Thus, these coordinated reactions in epithelium and connective tissue leads the OSMF toward malignant transformation.
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ORIGINAL ARTICLES Top

Kilovoltage cone-beam computed tomography imaging dose estimation and optimization: Need of daily cone-beam computed tomography p. 470
Gaurav Trivedi, Chandra K Dixit, Arun S Oinam, Rakesh Kapoor, Amit Bahl
DOI:10.4103/jcrt.JCRT_949_17  PMID:31169206
Aim: The aim of the present study was to access the need of daily cone-beam computed tomography (CBCT) and the requirement of in-house protocols of image acquisition frequency to reduce unnecessary exposure to the patients undergoing radiotherapy treatment. Materials and Methods: The dose delivered during CBCT procedure (On-Board Imager, Trilogy, Varian medical system, Inc., Palo Alto, California) was assessed for pelvic and head and neck region. For dose estimation, cylindrical polymethyl methacrylate phantoms of 15 cm length, 16 cm, and 32 cm diameter were used to simulate the patient's head and neck and pelvic region thickness, respectively. More than 10 cm scatterer was added on either end of this phantom. Calibrated Ionization chamber DCT10 LEMO SN 1685 iba, dosimetry, Germany (10 cm active length) was used to measure the dose Index. The doses known as cone-beam dose index (CBDI100) were estimated for all the scanning protocols (kV and mAs setting) available on the machine. In this study, image acquisition frequency to correct the setup error was optimized. In-house protocol for image acquisition frequency during treatment has been suggested to reduce the dose. It was based on the principle of as low as reasonable achievable. Results: Optimized dose protocol observed was the “standard dose head” for which the CBDI100 was 2.43 mGy. Whereas for pelvic imaging, single protocol of 125 kV, 80 mA was available by which a dose of 7.61 mGy is likely to be received by the patient during scan. Maximum shift of 6 mm in lateral direction was observed to the patient of Pelvis region and 5 mm was observed in the longitudinal direction for the H and N patients. Angular shift measured in patient position was 3.8° and 3.1° for H and N and pelvic region, respectively. Conclusion: Three consecutive-day CBCT-imaging at the beginning of the treatment followed by once weekly CBCT and two-dimensional (2D) imaging in remaining days of treatment can be an optimized way of imaging for the patient having malignancy in the region of pelvic and abdomen. For H and N, once in a week, CBCT with standard dose head protocol, followed by 2D-imaging in remaining days can be an optimized way of imaging.
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Optimization of low-energy electron beam production for superficial cancer treatments by Monte Carlo code p. 475
Rana Akbarpoor, Navid Khaledi, Xufei Wang, Farhad Samiei
DOI:10.4103/jcrt.JCRT_203_18  PMID:31169207
Context: Low energy electron beam has been being used widely for superficial cancer treatments. In the current study a design for production of very low energy electron beam, by different thickness of Perspex spoilers, is presented that may be used for skin cancer. Aims: MCNPX Monte Carlo code was used for modeling and simulations in the current study. An energy spoiler Perspex was modeled for degrading 4 MeV electron beam of Varian 2300 CD Linac. Materials and Methods: The thicknesses of 3, 7, and 10 mm were applied before electron applicator at a distance of 42 cm from phantom surface. Dosimetric properties of new electron beams including Rp, Dmax, E0, as well as the penumbra of the beam were investigated. Results: For the 3 mm spoiler, the superficial beam output decreased to 77%, and the Dmax, R90, R50, and RP were shifted to the depths of 4, 6, 9, and 12 mm, respectively. While for 10 mm filter the results were 5.2, 3.0 and 5.0 mm for R90, R50, and Rp, respectively. In addition, the surface dose was 93% and the Dmax was shifted to the depth of 1mm for the 10mm Perspex spoiler slab. Conclusions: The presented beam provides a novel surface dose, Dmax, and RP which can be applicable for treatment of skin cancers with minimum dose to the beyond normal tissues.
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Development of α-tocopherol surface-modified targeted delivery of 5-fluorouracil-loaded poly-D, L-lactic-co-glycolic acid nanoparticles against oral squamous cell carcinoma p. 480
Saurabh Srivastava, Shalini Gupta, Shadab Mohammad, Irfan Ahmad
DOI:10.4103/jcrt.JCRT_263_18  PMID:31169208
Objective: The aim of the study to develop surface modified targeted moiety α-tocopherol (α-t) encapsulated with 5-fluorouracil (5-FU)-poly-D, L-lactic-co-glycolic acid nanoparticles (PLGA NPs) toward the anticancer activity against oral squamous cell carcinoma (OSCC). Materials and Methods: 5-FU was conjugated with the polymer, PLGA by ionic cross-linking and α-tocopherol use as a functionalized surface moiety. Characterization, drug entrapment efficiency, and in-vitro drug release system were optimized at different pH 7.4 and pH 4.5. The in-vitro cell was performed to optimize the anticancer activity through MTT assay and apoptotic staining assay was also performed by flow cytometry to evaluate the cellular apoptotic activity and cellular uptake. Results: The particle size was distributed within an average range of 145–162 nm, the polydispersity index values lie 0.16–0.30, and the surface charge was at the negative side, –17mV to –23mV. The in vitro drug release system showed more sympathetic situation at pH 7.4 as compared to pH 4.5, for targeted NPs, approximately 86% and 69%, respectively. The non-targeted 5-FU-PLGA NPs showed drug release of 83% and 64% at pH 7.4 and 4.5 subsequently. In vitro anticancer activity confirmed the intense inhibition by α-t-FU-PLGA NPs of 79.98% after 96 h treatment of SCC15 cells and confirmed the steady-state inhibition of 83.74% after 160 h incubation in comparison to 5-FU-PLGA NPs. Subsequently, the early apoptosis, 27.98%, and 16.45%, and late apoptosis, 47.29%, and 32.57%, suggested the higher apoptosis rate in targeted NPs against OSCC. Conclusions: The surface modified α-t-FU-PLGA NP was treated over SCC15 cells, and the oral cancer cells have shown the high intensity of cellular uptake, which confirmed that the target moiety has successfully invaded over the surface of cancer cells and shown advanced targeted delivery against OSCC.
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A Monte Carlo study on dose perturbation due to dental restorations in a 15 MV photon beam p. 491
Mona Azizi, Ali Asghar Mowlavi, Mehdi Ghorbani, Courtney Knuap, Marziyeh Behmadi
DOI:10.4103/jcrt.JCRT_903_16  PMID:31169209
Aim: The main purpose of this study is to evaluate the effect of dose perturbation due to common dental restoration materials in the head and neck radiotherapy with a 15 MV external photon beam. Setting and Design: Teeth with three dental restorations such as tooth filled with Amalgam, Ni-Cr alloy, and Ceramco were simulated by MCNPX Monte Carlo code. In this simulation, the dental materials were exposed by a 15 MV photon beam from a Siemens Primus linac, inside a water phantom. Materials and Methods: A Siemens Primus linear accelerator and a phantom including: tooth only, tooth with Amalgam, tooth with Ni-Cr alloy, and tooth with Ceramco were simulated by MCNPX Monte Carlo code, separately. The percentage dose change was evaluated relative to dose in water versus depth for these samples on the beam's central axis. The absolute dose by prescription of 100 cGy dose in water phantom at 3.0 cm depth was calculated for water, tooth, tooth with Amalgam, tooth with Ni-Cr alloy, and tooth with Ceramco. Results: The maximum percentage dose change is related to tooth with Ni-Cr alloy, tooth, tooth with Ceramco, and tooth with Amalgam with amounts of 7.73%, 6.95%, 4.7%, and 3.06% relative to water at 0.75 cm depth, respectively. When 100.0 cGy dose was prescribed at 3.1 cm, the maximum absolute dose was 201.0% in the presence of tooth with Ni-Cr alloy at 0.75 cm. Conclusion: Introduction of the compositions of dental restorations can improve the accuracy of dosimetric calculations in treatment planning and protect the healthy tissues surrounding teeth from a considerable overdose.
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Analysis of induced error by susceptibility effect in low-density gel dosimeters p. 498
Farideh Pak, Vahid Vaezzadeh, Ehsan Eqlimi, Mona Mirheydari
DOI:10.4103/jcrt.JCRT_407_17  PMID:31169210
Purpose: In low-density (LD) gel dosimeter, diffusive spin–spin relaxation rate (R2)-dispersion caused by susceptibility-induced internal gradient leads to a significant deviation in the measured R2 from the real value. In this study, the effect of induced internal gradient on R2 was visualized and quantified algebraically as an important cause of inaccuracy in LD gel dosimeters. Materials and Methods: In this method, two sets of LD and unit-density (UD) gel dosimeters were prepared. The LD gel was made by mixing the UD gel with expanded polystyrene spheres. The R2 was used to determine the spatially resolved decay rates due to diffusion in internal magnetic field. The internal gradient was calculated for a multiple spin–echo sequence. Results: It is shown that in a LD gel, the internal gradient leads to overestimation of mean R2 value (R2mean). Pixel-by-pixel R2 measurements inside a LD gel showed significant deviation from R2 mapping in UD gel. Conclusion: It appears that significant differences between R2mean in a selected region of interest and pixel-by-pixel R2 values are the main source of inaccuracy in dose mapping of a LD gel.
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Improvement of dose distribution in ocular brachytherapy with 125I seeds 20-mm COMS plaque followed to loading of choroidal tumor by gold nanoparticles p. 504
Mansour Zabihzadeh, Hadi Rezaee, Seyed Mohammad Hosseini, Mostafa Feghhi, Amir Danyaei, Mojtaba Hoseini-Ghahfarokhi
DOI:10.4103/jcrt.JCRT_907_17  PMID:31169211
Aims and Objectives: Brachytherapy using removable ophthalmic plaques loaded with suitable small sealed radioactive seeds adjacent to the ocular's tumor has been widely used as an effective treatment. The aim of this study was to investigate the dose distribution in a modeled eyeball followed to loading of an ocular melanoma tumor with different concentrations of gold nanoparticles (GNPs) as dose enhancement agent by Monte Carlo (MC) calculations. Materials and Methods: The MC code of MCNPX 2.6.0 was used to modeling of COMS standard eye plaque loaded with 24 125I sources (6711 model) located on the sclera of modeled eyeball with detailed structures and materials. A choroidal melanoma tumor was simulated and loaded with different concentrations of spherical gold GNPs (50 nm in diameter). Dose enhancement factors (DEFs) of ocular components were calculated. Results: The dosimetric properties of 125I source (6711 model) and dose distribution of COMS standard eye plaque were calculated successfully as recommended by TG-43U1; AAPM. Loading of tumor with GNPs increased dose to the tumor and decreased dose to the normal tissues; the DEF was increased up to 2.280 and 2.030 for tumor apex, while it was decreased to 0.760 and 0.892 for macula and for gold-tumor mixture and nanolattice distributions, respectively. Conclusion: Loading the choroidal tumor volume with GNPs improves the dose distribution by increasing dose to the tumor and decreasing dose to the health components in ocular brachytherapy with 125I seeds 20-mm COMS plaque.
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Radioprotective effect of grape seed extract against gamma irradiation in mouse bone marrow cells p. 512
Reza Ghasemnezhad Targhi, Amin Banaei, Valiallah Saba
DOI:10.4103/jcrt.JCRT_243_17  PMID:31169212
Introduction: Ionizing radiations produce free radicals which are often responsible for DNA damage or cell death. Grape seed extract (GSE) is a natural compound having an antioxidant that protects DNA, lipids, and proteins from free radical damages. In this study, radioprotective effect of the GSE has been investigated in mouse bone marrow cells using micronucleus test. Materials and Methods: Four groups of mice were investigated in this study: Mice in Group 1 were subjected to injection of distilled water with no irradiation. Mice in Group 2 were exposed to 3 Gy gamma radiation after the injection of distillated water. Mice in Group 3 were injected with 200 mg/kg of the GSE without any irradiation. In another group, mice were exposed to three gray gamma irradiation after the injection of GSE. Animals were killed, and slides were prepared from the bone marrow cells 24 h after irradiation. The slides were stained with May Grunwald–Giemsa method and analyzed microscopically. The frequency of the micronucleated polychromatic erythrocytes (MnPCEs), micronucleated normochromatic erythrocyte (MnNCEs), and polychromatic erythrocyte/polychromatic erythrocyte + normochromatic erythrocyte (PCE/PCE + NCE) ratios was calculated. Results: Injection of GSE significantly decreased the frequency of MnPCEs (P < 0.0001) and MnNCEs (P < 0.05) and increased the ratio of PCE/PCE + NCE (P < 0.0001) compared to the irradiated control group. Discussion and Conclusions: GSE could reduce clastogenic and cytotoxic effects of gamma irradiation in mice bone marrow cells; therefore, it can be concluded that the GSE is a herbal compound with radioprotective effects against gamma irradiation. Free radical scavenging and the antioxidant effects of the GSE probably are responsible mechanisms for the GSE radioprotective effects.
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The effect of date palm seed extract as a new potential radioprotector in gamma-irradiated mice p. 517
Davood Khezerloo, Tohid Mortezazadeh, Bagher Farhood, Peyman Sheikhzadeh, Nayer Seyfizadeh, Laleh Pezhman
DOI:10.4103/jcrt.JCRT_1341_16  PMID:31169213
Objective: Date palm seed extract (DPSE) has various compounds revealing antioxidant features. This study aimed to evaluate the radioprotective effect of DPSE in total body gamma irradiation. Materials and Methods: At first, chemical characteristics of DPSE were analyzed by ultraviolet, visible and Fourier transform infrared spectroscopy. Then, the toxicity of DPSE was assessed. For this purpose, 60 mice were divided into five groups, and each of the groups were injected by the doses of 100, 200, 300, 400, and 500 mg/kg, respectively. At the termination of the experiment, mortality rate and weight loss of all mice were evaluated over a period of 30 days. Finally, the radioprotective effect of DPSE was evaluated by dividing 36 mice into three groups: control, test, and placebo and then were irradiated by Cobalt-60. Results: According to the findings, there was no mortality due to DPSE. Furthermore, for the maximum dose of 500 mg/kg, the number of mice surviving at the termination of the experiment with and without injection of DPSE was reported as 83% and 41%, respectively. In addition, a significant difference was obtained between radiated mice with and without DPSE injection (P = 0.035). Conclusion: The findings showed that DPSE injected into mice before irradiation has no toxicity and could protect mice from lethal effects of total body irradiation. The use of DPSE as a new radioprotector agent in the human needs further studies, particularly clinical trials.
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Dosimetric analysis and clinical outcomes of brachial plexus as an organ-at-risk in head-and-neck cancer patients treated with intensity-modulated radiotherapy p. 522
Bhanu B Prakash, Prahlad H Yathiraj, T Krishna Sharan, Anshul Singh, Anusha S Reddy, Srinidhi G Chandraguthi, Ramya Bala Subramanian, Jyothi Nagesh, Sarath S Nair, Donald J Fernandes, Vidyasagar S Mamidipudi
DOI:10.4103/jcrt.JCRT_959_17  PMID:31169214
Objectives: To document the dose received by brachial plexus (BP) in patients treated with intensity-modulated radiotherapy (IMRT) for head-and-neck squamous cell carcinoma (HNSCC) and report the incidence of brachial plexopathy. Methods: Newly diagnosed patients of HNSCC treated with radical or adjuvant IMRT were included in this retrospective study. No dosimetric constraints were applied for BP maximum dose equivalent dose (EQD2 α/β = 3). Patients with minimum 6-month follow-up were included and patients with suspicion of plexopathy were evaluated further. Results: Sixty-seven patients were eligible and 127 BP were analyzed. The mean BP maximum dose (BPmax) was 62.4 Gy (+6.9), while mean BP volume was 28.1 cc (+4.1). Proportion of patients receiving BPmax >66 and >70 Gy were 34.7% and 14.2%. The mean BPmax for T4 tumors was significantly higher than T1 tumors (65 vs. 57.5 Gy, P = 0.005) but when adjusted for N-category, T-category was not independently significant in accounting for BPmax >66 or >70 Gy. Mean BPmax for N0 versus N2+ was 59.8 versus 65.6 Gy (P = 0.0001) and N1 versus N2+ was 61.6 versus 65.6 Gy (P = 0.018). After adjusting for T-category, patients with N2+ had a mean 4.2 Gy higher BPmax than N0-N1 (P = 0.0001). Stage III–IV patients had a mean six Gy higher BPmax doses than Stage I–II disease (P = 0.0001). With a median follow-up of 28 months (interquartile range 16–42), no patient had brachial plexopathy. Conclusion: Clinically significant plexopathy was not seen in spite of majority having over 2-years follow-up and a third of patients having dose above the recommended tolerance. Only nodal category independently influenced dose to the brachial plexii.
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Role of hypofractionated palliative radiotherapy in patients with stage four head-and-neck squamous cell carcinoma p. 528
Ankur Mudgal, Ashok Kumar Arya, Indira Yadav, Sandeep Chaudhary
DOI:10.4103/jcrt.JCRT_116_18  PMID:31169215
Background: Large number of patients with head-and-neck cancer presents with factors such as advanced disease, poor general condition, and associated comorbidities due to which radical treatment is not recommended in these patients. In this scenario, the aim of the present study is to assess the role and feasibility of hypofractionated palliative radiotherapy in these patients. Subjects and Methods: This study was conducted on patients with histopathologically proven cases of squamous cell carcinoma of the head-and-neck region who were surgically unresectable. The quality of life (QOL) was assessed before and after 1 month of radiotherapy using University of Washington Quality of Life questionnaire version 4. All patients received 40 Gy in 10 fractions, twice weekly by two lateral fields covering primary and secondary disease. Response evaluation criteria in solid tumor criteria were used to assess the tumor response. Toxicity was assessed weekly using radiation therapy oncology group criteria. Results: A total of 50 patients were enrolled in this study, out of which 46 completed the planned treatment of 40 Gy in 10 fractions. Common complaints were distressing pain at the primary site (42%), neck swelling (30%), difficult in swallowing (18%), and change in voice (10%). Statistically significant improvements were observed in overall QOL (26.9 ± 9.63 to 55.65 ± 19.28) and none of them experienced Grade IV mucositis or skin toxicity. Good objective response was seen in 82.6% and 84.7% of patients at primary and nodal sites, respectively. Conclusions: This hypofractionated palliative radiotherapy regimen is a good treatment option in patients with Stage IV head-and-neck cancer, who are not fit for treatment with curative intent.
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Adaptive intensity-modulated radiotherapy in head-and-neck cancer: A volumetric and dosimetric study p. 533
Nagarjuna Burela, Tej Prakash Soni, Nidhi Patni, Thiru Natarajan
DOI:10.4103/jcrt.JCRT_594_17  PMID:31169216
Introduction and Objective: Anatomic and volumetric changes occur in head-and-neck cancer during fractionated radiotherapy (RT), and the actual dose received by patient is considerably different from the original plan. The purpose of this study is to evaluate volumetric and dosimetric changes occurring during radiation therapy. Patients and Methods: Ten patients of locally advanced head-and-neck cancer, 6 oropharynx, 3 larynx, and 1 hypopharynx underwent computed tomography (CT) simulation before treatment and after 4 weeks during RT treatment. Original plan (OPLAN) was generated based on initial CT scan for the entire course of treatment. The initial plan is implemented on the second planning CT scan, and the dose distribution is recalculated. Beam configuration of OPLAN was applied onto the second CT scan and then hybrid plan (HPLAN30) was generated. RPLAN30 is the intensity-modulated RT replan generated on the second CT scan for the remaining 30 Gy. Dose and volume parameters between OPLAN30 (based on the first CT scan for the remaining 30 Gy), HPLAN30, and RPLAN30 were compared. Results: The volume reduction of planning target volume (PTV), ipsilateral and contralateral parotid after 4 weeks of RT, was statistically significant (P < 0.05). D2% and V > 107% of PTV were higher in HPLAN than that of RPLAN (P < 0.05). Hybrid plans showed increase in delivered dose to spinal cord. Mid treatment replanning reduced doses to spinal cord (Dmax and D1%), which is statistically significant (P < 0.05). Mean doses to ipsilateral and contralateral parotid of RPLAN (21.4 Gy and 16.74 Gy, respectively) were reduced when compared to that of HPLAN (22.99 Gy and 22 Gy, respectively). Conclusion: Interim CT scanning and replanning (adaptive) improves target volume coverage and normal tissue sparing.
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Adjuvant radiotherapy in carcinoma buccal mucosa; more conformal the best: Is it so? p. 539
A S Kirthi Koushik, M G John Sebastian, MG Janaki, S Sathish
DOI:10.4103/jcrt.JCRT_101_17  PMID:31169217
Introduction: Since 1980s, computerization has made improvements in radiation therapy delivery from conventional two-dimensional to three-dimensional conformal radiotherapy (2DCRT to 3DCRT) to intensity-modulated radiotherapy (IMRT) and its newer versions. This small study is aimed to compare the existing techniques for planning target volume (PTV) and organ at risk (OAR) dose distribution parameters in postoperative buccal mucosa cases. Materials and Methods: Ten post operative cases of early stage carcinoma buccal mucosa in whom only post operative bed irradiation was indicated was enrolled and was planned with conventional, 3DCRT and IMRT techniques to get 95% PTV coverage and dose received by organs at risk were recorded and evaluated. Results: Mean and standard deviation values for PTV 95% for IMRT, 3DCRT, and conventional plans were 96.4 ± 1.8, 95.1 ± 1.9, and 91 ± 2.7, respectively. Dose received by OARs was high in conventional technique when compared to the other two. Maximum dose received by 1 cc of brain (46.2 ± 7.9 and 60.8 ± 3.8) (priority was given for PTV coverage) and mean dose received by the same eye (13.6 ± 1.4 and 22 ± 2.4) were less in IMRT when compared to 3DCRT. However, maximum dose received by 1 cc of brainstem (29.7 ± 7.6 and 14.1 ± 9.5), optic chiasma (29.2 ± 4.2 and 12 ± 2.1), spinal cord (31.8 ± 3 and 20.9 ± 4.2), and the same-side optic nerve (22 ± 6.9 and 11.7 ± 9.4) and mean dose received by opposite-side parotid (8.7 ± 1.1 and 1.7 ± 0.4) and submandibular gland (18.6 ± 1.7 and 3.2 ± 0.9) were more with IMRT when compared to 3DCRT. Conclusion: In postoperative cases of early-stage carcinoma buccal mucosa, it is good enough to treat with 3DCRT technique. Here, the target area will be well lateralized, and 3DCRT technique can give good target coverage and less dose to OARs, especially the only remaining major salivary glands.
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Measurement of eye and lens doses in the presence and absence of shield during whole brain irradiation p. 544
Bagher Farhood, Ghazale Geraily, Amir Hossein Goodarzi, Arman Zia, Mohsen Najafi, Somayeh Farahani
DOI:10.4103/0973-1482.191056  PMID:31169218
Aim: The aim was to measure doses of eyes and lenses in the presence and absence of shield during whole brain irradiation (WBI). In addition, the dose calculations accuracy of radiation therapy dose plan treatment planning system (TPS) in dose calculation of the eyes and lenses in WBI was evaluated. Materials and Methods: To measure the eyes and lenses doses during WBI, an inhomogeneous phantom of human head was used. Then, the eyes and lenses doses in the presence and absence of shield were measured by EBT3 film. Results: In single fraction with 200 cGy to reference point, average doses received by the left and right eyes in the absence of shield were 20 ± 1.5 and 22 ± 1.0 cGy, respectively, and for the left and right eyes in the presence of shield were 18 ± 2.2 and 21 ± 2 cGy, respectively. In addition, the average dose received by the left and right lenses in the absence of shield were 19.5 ± 0.5 and 18.5 ± 0.5 cGy, respectively, and for the left and right lenses in the presence of shield were 20.5 ± 1.5 and 19.5 ± 1.5 cGy, respectively. The results showed the TPS compared to the film underestimates doses for the eyes and lenses. Conclusion: The average dose received by the eyes and lenses during WBI were estimated around 9–11% of prescribed dose. According to the results, there is probability of radiation-induced cataractogenesis during WBI. By investigating the effect of shield on the lenses and eyes doses, using shield during WBI is not recommended. In addition, the results showed dose calculation accuracy of the TPS for the estimation of doses received by the eyes and lenses during WBI is not acceptable.
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Is excision repair cross-complementation Group1 expression a biological marker in nasopharynx carcinoma? p. 550
Asude Aksoy, Emin Tamer Elkiran, Hakan Harputluoglu, Adile Ferda Dagli, Abdurrahman Isikdogan, Zuhat Urakci
DOI:10.4103/0973-1482.206865  PMID:31169219
Objective: To determine the prognostic value of excision repairs cross-complementation group1 (ERCC1) gene in cases with nasopharyngeal carcinoma (NPC) treated with platinum-containing chemotherapy (PCT). Subjects and Methods: The present study was included 33 cases in local advanced stage with NPC. ERCC1 expression was evaluated by using immunohistochemical staining in biopsy specimens. We evaluated the relationship between the degree of ERCC1 expression and clinicopathological features, response to therapy, survival rates in cases with NPC, retrospectively. Results: ERCC1 expression was not observed in 5 (15.15%) of all cases. Thirteen (39.9%) cases weakly positive (+1, +2) and 15 (45.5%) cases of all them were rather strongly positive (+3). There was no statistically significant difference between the degree of ERCC1 expression and clinicopathological features, response to treatment, survival rates (P > 0.05) in cases with NPC. Conclusions: ERCC1 expression has no predictive value for survival in cases locally advanced stage with NPC. Evaluation of ERCC1 expression is not appropriate with a biomarker to detect cases who can benefit from PCT in NPC.
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Hypopharyngeal cancer risk in Japanese: Genetic polymorphisms related to the metabolism of alcohol- and tobacco-associated carcinogens p. 556
Yukashi Yamashita, Taro Ikegami, Mikio Suzuki, Hitoshi Hirakawa, Hiroyuki Maeda, Satoshi Yamada, Zeyi Deng, Shunsuke Kondo, Hidetoshi Kinjyo, Asanori Kiyuna, Shinya Agena, Takayuki Uehara, Akira Ganaha
DOI:10.4103/jcrt.JCRT_980_17  PMID:31169220
Background: Several studies have investigated hypopharyngeal cancer (HC) risk in combination with xenobiotic metabolism-related genetic polymorphisms and the burden of alcohol consumption and smoking in European countries but not in East Asian countries. Patients and Methods: This hospital-based case–control study involved 61 male patients with HC and 71 male cancer-free controls. Information on age, body mass index, and alcohol and cigarette consumption was obtained from medical records, a self-completion questionnaire, and a thorough interview by an otolaryngologist. Alcohol dehydrogenase 1B (ADH1B), aldehyde dehydrogenase 2 (ALDH2), cytochrome P450 A1 (CYP1A1) MspI, CYP1A1 Ile462Val, glutathione S-transferase (GST) M1, GSTT1, and GSTP1 gene polymorphisms were determined by polymerase chain reaction-based methods. Univariate and multivariate analyses were performed by adjustment for age by the Mantel–Haenszel method. Results: The burden of alcohol and cigarette consumption significantly increased the risk of HC and showed a synergistic effect. ADH1B*1/*1 (odds ratio [OR] 7.34) and ALDH2 *1/*2 (OR 13.22) were significant risk factors for HC. Individuals with ADH1B*1/*1 or ALDH2 *1/*2 who consumed alcohol were more susceptible to HC. However, polymorphisms of CYP1A1 gene and GSTs were not significant cancer risk factors in patients with HC. Conclusions: ADH1B*1/*1 and ALDH2 *1/*2 were significant risk factors for HC, while polymorphism of CYP1A1 gene and GSTs was not a significant risk factor for HC. These polymorphisms determined the effects of alcohol and cigarette smoke in addition to burden of alcohol and cigarettes intake on the risk of HC.
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A correlation of immunohistochemical expression of TP53 and severity of inflammation with varying grades of oral squamous cell carcinoma p. 564
Jay Ashokkumar Pandya, Srikant Natarajan
DOI:10.4103/jcrt.JCRT_8_17  PMID:31169221
Purpose: Epithelial cells exposed to carcinogens and genetic damage, once surpass reversible cell damage, either undergo apoptosis or transform into malignancy, chiefly oral squamous cell carcinoma (OSCC). Progressive accumulation of genetic errors in TP53 results in tumorigenesis. Inflammation is also a modulator in this process. The present study attempted to correlate the immunohistochemical expression of TP53 with increased aggressiveness of OSCC, to determine how these immune cells regulate the path of carcinogenesis and to define the role of inflammation in TP53 immunoexpression. Materials and Methods: Tissue sections from 24 biopsy-proven cases of OSCC were stained with anti-TP53 antibody. Five hundred neoplastic epithelial cells and inflammatory cells, each, were counted at invasive tumor front. Two hundred peritumoral neutrophils were counted based on nuclear lobes present. Results: The least TP53 expression was seen in well-differentiated OSCC (P < 0.001), whereas neutrophil count and plasma cell count were found to be least in well-differentiated OSCC (P < 0.001), whereas the number of lymphocytes and macrophages decreased with increased grading of OSCC (P < 0.001). Four- and five-lobed neutrophils were found to be highest in poorly differentiated OSCC (P < 0.001), whereas two-lobed neutrophil count was seen to be maximum in well-differentiated OSCC (P < 0.001). Conclusion: TP53 plays a significant role in the initiation and progression of OSCC. Inflammation plays a role of friend and a foe simultaneously, and little modification in the present treatment modalities for OSCC can bring a favorable change in the life of cancer survivors.
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Detection of human papillomavirus 16 and 18 in patients with oral squamous cell carcinoma and potentially malignant oral disorders in South Indian population: A pilot study p. 571
Karthika Panneerselvam, A Rameshkumar, K Rajkumar, Ramya Ramadoss
DOI:10.4103/jcrt.JCRT_1012_17  PMID:31169222
The Aim of the Study: Human papillomavirus (HPV) is an oncogenic virus and the high-risk genotype HPV 16 and 18 are the most commonly associated with carcinoma. The aim of the study is to determine the prevalence of HPV 16 and 18 in normal oral mucosa, potentially malignant oral disorders (PMOD), and in oral squamous cell carcinoma (OSCC) in South Indian population and whether it can be used as a biological marker to identify the severity of the disease in patients. Materials and Methods: Cytological samples from buccal mucosa were obtained from ten OSCC patients, ten patients with PMOD, and ten from control group. The samples were subjected to polymerase chain reaction. Results: The prevalence of HPV 16 in control, PMOD, and OSCC was 80%, 50%, and 70%, respectively. The prevalence of HPV 18 in control, PMOD, and OSCC was 70%, 60%, and 50%, respectively. Conclusion: HPV 16 and 18 was noticed in normal oral mucosa, potentially malignant oral lesions, and SCC. The absence of sequential increase or decrease of HPV 16 and 18 in the three groups in this study prevents its use from being used as a marker to identify the progression of the disease.
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Patterns of failure for early-stage glottic carcinoma: 10 years' experience in conformal radiotherapy era p. 576
Fatma Sert, Isa Kaya, Kerem Ozturk, Mustafa Esassolak
DOI:10.4103/jcrt.JCRT_692_17  PMID:31169223
Purpose: Larynx cancer is the most common head-and-neck cancer in Turkey. Vocal cords are involved nearly 70%–80% of laryngeal carcinomas. We aim to present our 10 years' experience and failure patterns of the patients with T1 and T2 glottic laryngeal carcinoma by same manner, technique, doses, and physician in conformal radiotherapy (RT) era. Methods: Between January 2005 and December 2015, a total of 143 patients treated with definitive RT for early-stage glottis laryngeal cancer were selected. The total dose was 65.25 Gy in 29 fractions. Results: The median follow-up time was 64 (range: 12–150) months. All of the patients had a complete clinical response to the treatment. A 5-year local control (LC) rates were 84.5%, 91.8%, 74%, and 56% for overall, T1a, T1b, and T2, respectively. Ultimate LC rates (after salvage treatment) for 5 years were 90%, 95%, 92%, and 75% for overall, T1a, T1b, and T2, respectively. Regional neck control for the whole group was 92% for 5 years. After the initial RT, a total of 22 (15.4%) patients had disease recurrence at any site of the neck or larynx. Median time to disease recurrence was 59.5 months (range: 5–150). Conclusion: This study represents a large and long-term analysis of early-stage glottic carcinoma treated by same manner, technique, doses, and physician in conformal RT era. Definitive RT provides a high LC rate, tolerable toxicity, and favorable voice quality. Extension beyond the vocal cords and T2 stage are the most important unfavorable prognostic factors regarding LC.
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Impact of smoking on pathological features in oral cavity squamous cell carcinoma p. 582
Karine A Al Feghali, Ahmed I Ghanem, Charlotte Burmeister, Steven S Chang, Tamer Ghanem, Christian Keller, Farzan Siddiqui
DOI:10.4103/jcrt.JCRT_641_16  PMID:31169224
Objectives: We sought to determine whether smokers with oral cavity squamous cell carcinoma (OCSCC) have tumors with more adverse pathological features than in nonsmokers and whether or not these are predictive of outcomes. Materials and Methods: We retrospectively identified 163 patients with American Joint Committee on Cancer stages I–IVa OCSCC diagnosed between 2005 and 2015 and treated with curative intent. A pathological risk score (PRS) was calculated using the National Comprehensive Cancer Network adverse risk factors: positive margin, extracapsular extension of lymph node metastases, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, and lymphovascular space invasion. Multivariable models were constructed to determine the independent predictors of overall survival (OS), recurrence-free survival (RFS), and PRS. Results: A total of 108 (66.26%) were smokers and 55 nonsmokers. Three-year actuarial OS and RFS were 62% and 68% in smokers and 81% and 69% in nonsmokers, respectively (P = 0.06 and P = 0.63). Smokers were more likely to have advanced disease stage and tumors with aggressive pathological features than nonsmokers. Smokers had significantly worse PRS (mean ± standard deviation; 2.38 ± 2.19, median; 2.00) than nonsmokers (0.89 ± 1.21, 0.00) (P < 0.001). Older age, higher PRS, and smoking status were independent predictors of OS. Smoking or PRS did not predict for worse RFS. On multivariate analysis, independent predictors of PRS were smoking status and grade (P < 0.001). Conclusion: In patients with OCSCC, smokers have more aggressive disease as evidenced by more adverse pathological features than nonsmokers. Moreover, smoking is an independent predictor of OS but not RFS. The PRS is a significant predictor of OS and needs validation in the future studies.
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The relationship between positron emission tomography-computed tomography imaging and histopathological features of thyroid incidentalomas detected during follow-up for primary malignancy p. 589
Bala Basak Oven, Zeynep Gamze Kilicoglu, Ahmet Bilici, Mehmet Tarik Tatoglu, Sule Canberk, Metin Tilki, Fugen Aker Vardar
DOI:10.4103/jcrt.JCRT_889_16  PMID:31169225
Aim of the Study: While the rate of thyroid incidentaloma detected on positron emission tomography (PET) was reported as 4%, the malignancy rate was 14%–50%. We evaluated the thyroid nodules which were detected by PET-computerized tomography (CT) in cancer patients and analyzed the pathological results of those thyroid nodules diagnosed by fine needle aspiration biopsy (FNAB) and their correlation with the maximum standardized uptake (SUVmax) value and PET imaging features. Materials and Methods: FNAB were performed for 40 thyroid incidentalomas. We analyzed the relationship between the histopathological findings and radiological features by Pearson's correlations and Chi-square-Fisher's exact tests to evaluate the factors associated with SUVmax. Results: The median SUVmax values were 5.4 for thyroid nodules. Totally, 14 malignancies were detected by FNAB (35%).The sensitivity and specificity of SUVmax value for diagnosis of malignancy were 87.5% and 52%, respectively. Positive and negative predictive values were 36.8% and 92.8%. The most common malignant and benign pathologies were classic variant papillary carcinoma and benign colloidal nodule. The median SUVmax was the higher in colon cancer thyroid metastasis and oncocytic neoplasia (SUVmax 14.5 and 13.6, respectively). Histopathological type was not related with nodule size but positively associated with categorical SUVmax(r = 0.318, P = 0.04) and negatively correlated with both the density of the thyroid nodule in PET-CT (r = −0.0042, P = 0.01) and density of nodule in ultrasound (USG) (r = −0.305, P = 0.05). Margin of the thyroid nodule in USG (P = 0.007) and internal component of the nodule in PET (P = 0.03) were found to be important factors to differentiate benign or malignant lesion. Conclusion: If the thyroid nodule is detected with flouro-2-deoxy-D-glucose uptake, to differentiate benign nodule from malignant, cytological examination is noteworthy to diagnose the more aggressive type of thyroid nodule and also thyroid metastasis from primary cancer.
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Prognostic value of response assessment fluorodeoxyglucose positron emission tomography-computed tomography scan in radically treated squamous cell carcinoma of head and neck: Long-term results of a prospective study p. 596
Sarbani Ghosh-Laskar, Naveen Mummudi, Venkatesh Rangarajan, Nilendu Purandare, Tejpal Gupta, Ashwini Budrukkar, Vedang Murthy, Jai Prakash Agarwal
DOI:10.4103/jcrt.JCRT_542_17  PMID:31169226
Objective: The objective of this study is to evaluate the diagnostic and prognostic ability of fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan in patients with squamous cell carcinoma of the head and neck treated with chemoradiotherapy or radiotherapy only. Materials and Methods: Fifty-nine patients with HNSCC planned for radical nonsurgical treatment were randomized to receive either three-dimensional conformal radiotherapy or intensity-modulated radiation therapy. In addition to routine clinical examination and staging investigations, patients had a FDG PET-CT scan at baseline and on the first follow-up for response assessment. No evidence of clinicopathological disease for at least 6 months after the completion of treatment was considered confirmation of complete response. The presence or absence of disease during the follow-up period was used to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for the primary site and node. Results: At a median follow-up of 52.5 months, 55.6% of patients were alive and disease free. Response assessment PET-CT was done at a median of 9 weeks (range: 5–18 weeks). PET-CT assessment of the primary had sensitivity, specificity, PPV, and NPV of 81.8%, 93%, 75%, and 95.2%, respectively; the corresponding figures at the node were 44.4%, 95.6%, 66.7%, and 89.6%. The median baseline maximum standardized uptake value (SUVmax) at primary and node was 14.9 and 8.1, respectively. When PET-CT was done after 10 weeks, no false-positive or false-negative findings were seen. Patients with negative PET at the first follow-up had a significantly better progression-free and overall survival. Conclusions: Disease evaluation using PET-CT has an overall accuracy of 80%. High baseline SUVmax correlates with worse clinical outcomes. Negative PET-CT at the first follow-up is a predictor for survival.
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Oral malignancy and its fickle blow off: A retrospective study p. 604
Rajnish Nagarkar, Ashvin Wagh, Gauri Kokane, Sirshendu Roy, Vijay Palawe, Nayana Kulkarni, Samadhan Pawar
DOI:10.4103/jcrt.JCRT_188_18  PMID:31169227
Background: The aim of this study was to retrospectively evaluate various patterns of failure in patients with oral squamous cell carcinoma and to estimate overall survival (OS) and disease-free survival (DFS) in failure patterns. Materials and Methods: Retrospective data of 500 patients operated for oral malignancy were obtained from year 2011 to 2014. Incidence of local, regional, and distant failure as well as DFS and OS was calculated. Furthermore, we studied various prognostic factors such as habits and coexistent comorbid conditions, depth of invasion, histological grade of tumor, and primary site of tumor. Results: Average DFS was 13.9 months and average overall survival was 55.77 months. The overall incidence of recurrence was 42.4%. Incidence of local recurrence was 24%, regional recurrence was 11.2%, and distant failure was seen in 7.2% of cases. Conclusion: Despite execution of standard treatment protocol comprising of surgery and chemoradiation, incidence of recurrence remains sententious in oral malignancy.
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A study on the clinical indicators in the diagnosis of orofacial nonodontogenic tumors p. 608
Dickson Sopuru Okoh, Mercy Okoh, Felix Osawe Omoregie, Michael Akin Ojo
DOI:10.4103/0973-1482.199377  PMID:31169228
Objective: This study aims to determine the clinical features which are helpful as significant indicators in the diagnosis of malignant and nonmalignant nonodontogenic orofacial tumors. Materials and Methods: This was a prospective study performed on patients with swellings in the oral and maxillofacial region clinically suspicious of being tumors of nonodontogenic origin in a Nigerian Tertiary Health Institution. The statistical variables that were analyzed included patients' resume, clinical and radiological features as well as the histopathological diagnosis of the lesions. The level of significance was set at P < 0.05. Inferential analysis was done using Student's t-test, Chi-square, binary logistic regression, and adjusted odds ratio as appropriate. Results: There were forty patients histopathologically diagnosed as nonodontogenic tumors of the orofacial region. Twenty-five (62.5%) were females and 15 (37.5%) were males with mean age of 36 ± 21.9 years. Histopathological features showed three different categories of the lesions: Reactive and benign (nonmalignant) and the malignant lesions. Lymphadenopathy (P = 0.035) and nonmobility of the swellings (P = 0.029) were significant clinical indicators that were strongly associated with histological diagnosis of the malignant nonodontogenic tumors. Conclusion: This study showed that the nonodontogenic tumors occurred mostly in younger patients with a female preponderance. The mandible and the preauricular region were the most common sites. Lymphadenopathy and nonmobility of the swellings were strong clinical indicators for the diagnosis of the malignant nonodontogenic tumors.
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Comparison of different stains in exfoliated oral mucosal cell micronucleus of potentially malignant disorders of oral cavity p. 615
Jatin Gupta, Kanupriya Gupta, Rahul Agarwal
DOI:10.4103/jcrt.JCRT_1326_16  PMID:31169229
Background: Micronucleus (MN) has been proved to be an important biomarker of genomic damage. Leishman Giemsa (LG) cocktail, being a relatively new staining technique, has not been used in exfoliative cytology. The aim of this study is to observe and compare the micronuclei (MN) frequency in potentially malignant disorders (PMDs) and also to compare the staining efficacy of May-Grünwald Giemsa (MGG), LG cocktail, and Papanicolaou (PAP) for micronuclei in exfoliated oral mucosal cells. Materials and Methods: Three smears were prepared from each 30 controls (buccal mucosa) and 120 patients (40 oral submucous fibrosis, 40 lichen planus, and 40 leukoplakia) clinically diagnosed with having one of the PMDs of the oral cavity stained with PAP, MGG, and LG cocktail stains. MN frequency (No. of MN/1000 cells) was evaluated and compared between the cases and the controls. Comparison between the three different stained smears was also made to determine the clarity and efficacy of the stains. Results: LG cocktail gave comparatively better results followed by PAP and MGG. Statistically significant results (P < 0.05) were obtained, using Mann–Whitney test for comparison of MN frequency between cases and controls. Conclusion: LG cocktail is an easy, cost- effective, and one step technique comparable to PAP staining; however, it warrants further study in its potential application in screening of oral cancer.
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A correlation between oral mucosal lesions and various quid-chewing habit patterns: A cross-sectional study p. 620
ML Avinash Tejasvi, CK Anulekha, Mohd Malik Afroze, K Prashanth Shenai, Laxmikanth Chatra, Harsha Bhayya
DOI:10.4103/jcrt.JCRT_620_14  PMID:31169230
Background and Objectives: Quid-chewing habit is a common and old tradition in India. It causes various potentially malignant disorders. Therefore, a study was undertaken to analyze the association of various quid-chewing habit patterns and different oromucosal lesions. Materials and Methods: A cross-sectional study was conducted on 150 cases, where all the individuals selected were having quid-chewing habit and oromucosal lesions. Detailed habit history was taken through preformed questionnaire, clinical examination was done, and the lesion was subjected to incisional biopsy and confirmed histopathologically. Results: The male to female ratio of various quid-chewing habit and oromucosal lesions was 9:1. The middle aged were more commonly involved. Of the various types of quids chewed, a combination of processed betel and processed tobacco which is commercially available was used by majority of the individuals. Oral submucous fibrosis (OSMF) was seen in majority of the cases. Interpretation and Conclusion: The present study confirms the association between betel, tobacco, and various lesions such as OSMF, leukoplakia, chewer's mucosa, lichenoid reaction, and chemical burn. It also confirms the strong association of betel to OSMF and tobacco to leukoplakia.
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Impact of stromal CD45RO+ immune cells on proliferation and dedifferentiation in node-negative squamous cell carcinomas of cheek mucosa p. 625
Vijay Wadhwan, Arvind Venkatesh, Pooja Aggarwal, Vandana Reddy, Preeti Sharma, Suhasini Gotur Palakshappa
DOI:10.4103/jcrt.JCRT_263_16  PMID:31169231
Background: The most fundamental trait of cancer cells involves their ability to sustain chronic proliferation. Tumors have a complex cellular ecology that establishes the malignant potential of the tumor. In these ecosystems, innate immune cells are highly represented. Many contradictory reports have been published regarding the impact of tumor-infiltrating immune cells on proliferation of the tumors. Aim: This study aims to assess the impact of CD45RO+ve immune cells on proliferation and dedifferentiation of node-negative squamous cell carcinomas of cheek mucosa (SCC-CM). Materials and Methods: Thirty formalin-fixed paraffin-embedded tissue blocks of previously diagnosed node-negative SCC-CM subclassified as Grade I SCC – 10 cases; Grade II SCC – 10 cases; and Grade III SCC – 10 cases (Broders' classification – 1927). Immunohistochemistry performed on each selected tissue section using anti-p53 and anti-CD45RO as primary antibodies. Semi-quantitative analyses performed for all the tissue sections to assess the p53 and CD45RO expression. p53:CD45RO expression ratio calculated. The data were statistically analyzed using GraphPad Prism 5 for Windows. Results: Our results showed statistically significant increase (P = 0.0006) in p53 expression and decrease (P = 0.0044) in CD45RO+ immune cell response with the decrease in differentiation of SCC-CMs using Fisher's exact test and statistically significant increase (P < 0.001) in p53:CD45RO expression ratio with decrease in differentiation using one-way ANOVA. Conclusion: Based on all these findings from the present study, we perceive the following findings. In node-negative SCC-CMs, CD45RO+ immune cells play a possible role in controlling the dedifferentiation of the tumor and in limiting the proliferative potential of the tumor cells which are tumor antagonistic in nature.
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Cell cannibalism in oral cancer: A sign of aggressiveness, de-evolution, and retroversion of multicellularity p. 631
Safia Siddiqui, Anil Singh, Nafis Faizi, Aeman Khalid
DOI:10.4103/jcrt.JCRT_504_17  PMID:31169232
Background: According to Darwin's theory of evolution, complex creatures evolve from more simplistic ancestors. Dollo's law of irreversibility states that evolution is irreversible. However, cancer cells tend to follow anti-Dollo's law. Unfavorable conditions such as hypoxia, acidic pH and low nutrients cause the cancer cells to switch their lifestyle atavistically in order to survive. They start behaving like a unicellular organism. There is a switch from normal metabolism to Warburg effect and finally cannibalism. Cannibalism is a cell eating cell phenomenon. It is defined as a large cell enclosing a smaller one within its cytoplasm and is known by odd names such as “bird's eye cells” or “signet ring cells.” Smaller tumor cells are found in the cytoplasm of larger tumor cells with crescent-shaped nucleus. Cannibalistic cells (CCs) are a feature of aggressive tumors. These cell types are vulnerable to metastasis. Aim: The aim of this study is to identify CCs in various histological grades of oral squamous cell carcinoma (OSCC) and to relate them with the pattern of invasion, lymphocytic response (LR), and mitotic figures (Mfs). The purpose of the article is to establish it as a marker of aggressiveness and metastasis and as an evidence of de-evolution and retroversion of multicellularity. Materials and Methods: Sixty-five histologically confirmed cases of OSCC were studied. Pattern of invasion, LR, number of CCs, and Mfs were recorded on 5 μ hematoxylin and eosin-stained tissue sections. ANOVA and t-test were applied; P < 0.05 was considered statistically significant. Results: CCs were more in sections with patchy LR, increased Mfs, and grade IV pattern of invasion. Conclusion: With increase in dedifferentiation, tumor cells start behaving like unicellular organisms with cell eating cell characteristics.
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Quality of life of patients with head and neck cancer: A mixed method study p. 638
Shalini G Nayak, Mamatha Shivananda Pai, Linu Sara George
DOI:10.4103/jcrt.JCRT_1123_16  PMID:31169233
Aim of the Study: The current research was conducted with the aim of determining the quality of life of head and neck cancer (HNC) patients using mixed method approach. Methods: A mixed method triangulation design (QUAN + QUAL) was adopted in the study. Quantitative data were collected among 54 and qualitative data were collected till data saturation using nested sampling technique. Data were collected from seven oncological wards of two tertiary care hospitals during the 4th week of radiation therapy. Quantitative data were collected through functional assessment of cancer therapy: head and neck, and a semi-structured interview schedule was adopted to elicit their experiences. Quantitative and qualitative data were compared during the analysis phase. Both qualitative and quantitative data were depicted in meta-matrices. Results: Results showed that the most affected domains were functional well-being followed by HNC subscale. Similar findings were observed in narrative description of participants. Most focused experience was pain, and difficulty in eating and swallowing was experienced due to pain. Their verbal communication was inefficacious due to loss of voice and tone. Moreover, communication was difficult owing to changes in the oral mucous membrane and pathology. Conclusion: Patients with HNC suffer from varying degrees of psychosocial problems, and it is important to identify the psychosocial adjustment of the patients since the symptoms are sufficient to lay heavy burden.
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Assessment of fatigability, depression, and self-esteem among head-and-neck carcinoma patients in a tertiary care hospital in South India p. 645
Nitin Joseph, PU Prakash Saxena, Apeksha Shettigar, Shashidhar M Kotian
DOI:10.4103/jcrt.JCRT_277_17  PMID:31169234
Background: Head and Neck Carcinoma (HNCs) are the most common form of cancer in India. Patients with head-and-neck carcinomas often suffer from various distressing symptoms. The exact cause of these symptoms, as to whether disease or treatment or other factor induced, needs to be established. Objectives: This study was done to assess fatigability, depression, and self-esteem among HNC study group before start, during, and in postradiation period and to find out the determinants of these parameters. Materials and Methods: Seventy newly diagnosed HNC patients and equivalent number of age- and gender-matched controls were interviewed using standardized questionnaires, before start of concurrent chemoradiotherapy (CCRT). The study group patients were interviewed again in the 4th week and postcompletion of CCRT in the 7th week. Results: Mean age of the study group was 55.1 ± 11.3 years. Three-fourth of them (52 [74.3%]) were males. Majority of them (26 [37.1%]) had oral carcinomas. Baseline fatigue (P < 0.001) and depression scores (P < 0.001) were significantly more, while self-esteem scores (P = 0.004) were significantly less among the study group compared to controls before the onset of radiation. Mean fatigue and depression scores were found to significantly increase (P < 0.001), while self-esteem scores were found to significantly deteriorate (P < 0.001) over the course of CCRT among these patients. There was significant positive correlation (P < 0.001) between fatigue and depression scores and negative correlation (P < 0.001) of these parameters with self-esteem scores before, during, and after CCRT. There was no association between age and gender of the study group with any of these parameters. Multivariate analysis showed that baseline fatigue was significant (P < 0.001) and, depression after completion of the entire course of CCRT was significantly influenced by baseline depression levels (P = 0.011). Conclusions: Fatigue and depression need to be periodically screened among HNC study group on CCRT so as to initiate prompt remedial measures for its alleviation.
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Reliability and psychometric validity of Hindi version of Depression, Anxiety and Stress Scale-21 (DASS-21) for Hindi speaking Head Neck Cancer and Oral Potentially Malignant Disorders Patients p. 653
Kapila Kumar, Sumit Kumar, Divya Mehrotra, Sarvada Chandra Tiwari, Vijay Kumar, Raghav Chandra Dwivedi
DOI:10.4103/jcrt.JCRT_281_17  PMID:31169235
Background and Objectives: The aim of the present study was to carefully translate and psychometrically validate the depression, anxiety, and stress scale-21 (DASS-21) in Hindi language for Hindi-speaking head and neck cancer (HNC) and oral potentially malignant disorder (OPMD) patients. Materials and Methods: One hundred and sixty-seven HNC and OPMD patients were recruited for this study comprising of 111 oral cancer and 56 OPMD patients. According to internationally accepted guidelines, forward and backward translation procedures were performed, to develop a culturally acceptable version of DASS-21. Validated Hindi version of hospital anxiety and depression scale (HADS) questionnaire was used to compare the scores. Internal consistency for construct validity of the DASS-21 was assessed. Related data and the patients' demographics details were recorded. Factor analysis using varimax rotation was also carried out. Results: The Cronbach's alpha values were 0.998, 0.990, and 0.994, respectively, for depression, anxiety, and stress domains, which was comparable to other studies and indicated a strong internal consistency and good construct validity. Factor and varimax analysis revealed items to be well suited to their respective domains. A statistically significant strong correlation was reflected with HADS Hindi questionnaire; Spearman's rank correlation values observed were 0.80 and 0.83 for depression and anxiety, respectively. Interpretation and Conclusions: Hindi version of the DASS-21 questionnaire appears to be culturally appropriate, reliable, and psychometrically valid tool for evaluation of the psychological burden (depression, anxiety, and stress) in Hindi-speaking HNC and OPMD patients.
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Clinicopathological analysis of extracranial head and neck schwannoma: A case series p. 659
Preeti Sharma, Sufian Zaheer, Surbhi Goyal, Charanjeet Ahluwalia, Ankur Goyal, Geet Bhuyan, Ashish Kumar Mandal
DOI:10.4103/jcrt.JCRT_1125_16  PMID:31169236
Background: Extracranial head and neck schwannomas are rare tumors which are often clinically misdiagnosed. Preoperative diagnosis of these tumors is challenging but imperative for surgeons so as to avoid nerve damage during excision. Materials and Methods: Sixteen patients diagnosed with extracranial head and neck schwannomas over a period of 2 years were retrospectively analyzed. Clinical details including preoperative fine-needle aspiration cytology (FNAC) and/or computed tomography (CT)/magnetic resonance imaging (MRI) findings were retrieved. FNAC smears and formalin-fixed paraffin-embedded sections were evaluated. Results: Among these 16 tumors, 6 (37.5%) were located in the lateral aspect of neck, 4 (25%) in scalp, 2 (12.5%) in orbit, and one each (6.25%) in palate, tongue, submandibular gland and parotid gland. The mean patient age was 31.3 years. FNAC was performed in 14 cases, of which 8 cases (58.3%) showed features of benign nerve sheath tumor (BNST), two cases (14.2%) were inconclusive with possibility of mesenchymal lesion, two cases (14.2%) were inadequate, one case (8.3%) showed features suggestive of schwannoma, and a diagnosis of nerve sheath tumor inconclusive for malignancy was rendered in a single case. The sensitivity of FNAC in diagnosis of BNST was 71.4%. CT or MRI was performed in five cases, of which an accurate diagnosis was rendered only in one case of orbital schwannoma. Conclusion: Imaging has a limited role in the preoperative diagnosis of head and neck schwannomas owing to nonspecific radiological features. Cellular aspirate smears are helpful in accurate diagnosis even at unusual locations.
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Nonthyroidal metastatic lesion in thyroid: A missed diagnosis and a lesson learnt p. 665
Chelakkot G Prameela, Rahul Ravind, K Sruthi
DOI:10.4103/jcrt.JCRT_1043_16  PMID:31169237
Background: Blood supply to the thyroid is relatively high when compared to that of liver. Despite this documented metastatic deposit in thyroid remains a rarity. Synchronous nonthyroidal metastatic deposit in thyroid from a lung primary is relatively rare. Metastasis to thyroid portends to poor prognosis, and hence a metastatic deposit has to be excluded in any suspicious lesion of thyroid. Materials and Methods: Details of a rare presentation of a malignant thyroid lesion, a secondary deposit from an asymptomatic primary papillary adenocarcinoma of lung, who had presented to this tertiary care center was retrieved and analyzed. Results: Patient with an initial diagnosis of papillary carcinoma on FNA was taken up for total thyroidectomy and cervical lmphadenectomy. HPR was mucinous carcinoma of thyroid with high lymph nodal metastasis. In view of the exrathyroidal disease an adjuvant external beam radiotherapy was considered for him. Unfortunately, the radiotherapy planning CT scan revealed left sided lung lesions with pleural effusion which was proved to be papillary adenocarcinoma of lung on biopsy, with metastases to thyroid. He was treated with chemotherapy but he succumbed to his illness 9 months from the date of diagnosis. Conclusion: Although encountered rarely, metastatic lesions in thyroid from nonthyroidal primaries need to be excluded while evaluating thyroid lesions.
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Primary thyroid lymphoma: A series from a tertiary care center in Northern India p. 669
Aanchal Kakkar, Suvendu Purkait, Shipra Agarwal, Supriya Mallick, Ajay Gogia, Asis Kumar Karak, Mehar Chand Sharma, Pramod Kumar Julka
DOI:10.4103/jcrt.JCRT_135_17  PMID:31169238
Objective: Primary thyroid lymphoma (PTL) is a rare entity, necessitating accurate and early diagnosis, as its management is very different from that of other neoplasms intrinsic to the thyroid. Materials and Methods: Cases diagnosed between January 2009 and March 2015 were retrieved, and clinical details were noted. Hematoxylin- and eosin-stained slides were reviewed. Immunohistochemistry (IHC) was performed for immunophenotyping, and cases were classified according to the World Health Organization 2017 classification of hematolymphoid neoplasms. Results: Eleven patients with PTL were identified, with a mean age of 64.6 years (range: 40–76 years), including three males and eight females. Duration of symptoms ranged from 2 to 36 months (mean: 9.3 months). Diffuse large B-cell lymphoma (DLBCL) was most frequent, followed by extranodal marginal zone lymphoma. Most DLBCLs were nongerminal center type. BCL2 was positive in all DLBCLs. Strong p53 immunopositivity was not seen in any of the cases analyzed. Conclusion: Histopathological evaluation supplemented by IHC is the gold standard for the diagnosis of PTL. Combined chemoradiotherapy appears to be the best treatment modality, irrespective of histological type. MIB-1 and MUM1 IHC may have a role in identifying DLBCL, particularly in small biopsies. Role of p53 and BCL2 needs further evaluation.
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Incidence of thyroid cancer and medical cost among patients with newly diagnosed thyroid nodules in Korea: A retrospective cohort study using nationwide data Highly accessed article p. 676
Min Kyung Hyun, Jong Hee Kim, Jin Won Kwon
DOI:10.4103/0973-1482.204895  PMID:31169239
Aims: The frequency of newly diagnosed thyroid nodules is increasing in South Korea. However, few studies have investigated the incidence of thyroid cancer in patients with thyroid nodules using national data. Therefore, this study was conducted to investigate the incidence of thyroid cancer and medical costs among patients newly diagnosed with thyroid nodules in South Korea. Settings and Design: This was a retrospective cohort study. Subjects and Methods: We analyzed the national health claim database, which includes all hospital records and covers almost every population managed by the National Health Insurance System. We selected patients aged 20–120 years with new thyroid nodules in 2008 using the International Classification of Diseases, Tenth Edition codes. We followed the selected cases for at least 2 years after thyroid nodule diagnosis to investigate cancer development and medical costs. Statistical Analysis Used: Frequency analysis was used. Results: We identified 283,844 eligible patients with thyroid nodules. Their mean age was 48 ± 13.2, and 234,388 (82.58%) cases were female. During the median follow-up of 2.4 years, 21,538 (7.6%) patients were diagnosed with thyroid cancer, and 93.5% of them underwent treatment such as thyroidectomy, chemotherapy, or radiotherapy. The average medical cost was 3,996,391 KRW after diagnosis of thyroid cancer. Conclusions: Here, national representative statistics regarding the incidence and medical costs of thyroid nodule and thyroid cancer are presented. The information provided herein will improve understanding of the natural course of thyroid nodules in Asians. Further study is needed to identify the risk factors of thyroid cancer in patients with thyroid nodules.
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The prognostic factors for clinical N1b patients in thyroid papillary carcinoma p. 681
Ulvi Murat Yuksel, Sevim Turanli, Yunus Acar, Ugur Berberoglu
DOI:10.4103/jcrt.JCRT_1011_16  PMID:31169240
Background: The aim of this study is to determine the prognostic factors which affect both disease-free survival (DFS) and overall survival (OS) in thyroid papillary carcinoma with clinical lateral lymph node metastasis. Methods: One hundred and three papillary thyroid carcinomas diagnosed in adult patients received therapeutic lateral neck dissection between December 1989 and June 2010 were analyzed retrospectively. All of the patients were classified as American Thyroid Association (ATA) intermediate risk category. Age, gender, tumor stage and size, multicentricity and bilaterality, vascular invasion and extrathyroidal invasion, ipsilateral/contralateral lymph node involvement, lymph node ratio, extranodal tumor extension, and development of recurrence were the factors which might affect disease-free and OS. Univariate and multivariate analyses were performed. ROC analysis was used to find the cutoff value for lymph node ratio. Results: One hundred and three patients were followed median 101 months. Locoregional or systemic recurrence developed in 20 patients (19.4%) while 7 patients (6.8%) had persistent disease. In multivariate analysis, lymph node ratio (P = 0.003, relative risk [RR] 5.4, 95% confident interval [CI] 1.7–16.5) and contralateral lymph node involvement (P = 0.02, RR 4.9, 95% CI 1.3–18.5) were the independent factors affecting DFS where contralateral lymph node involvement (P = 0.009, RR 44.4, 95% CI 2.5–765.2) was the only factor which affected OS. Conclusions: Lymph node ratio and contralateral metastasis affect DFS while contralateral metastases only affect OS in patients with N1b thyroid papillary carcinoma.
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Fine needle aspiration cytology of minor salivary gland tumors: A retrospective 5-year study of 42 cases in a tertiary care hospital p. 686
Subrata Pal, Sajeeb Mondal, Kingshuk Bose, Rajashree Pradhan, Arindam Bandyapadhyay, Debosmita Bhattacharyya
DOI:10.4103/0973-1482.191055  PMID:31169241
Background: Minor salivary gland tumors (MSGTs) are less common than major salivary glands and involve only 15–20% of all salivary gland tumors. Most of the cases originate at intra- and peri-oral region. Minor salivary gland lesion cytology has been studied rarely in India. Aims: This present study was performed to evaluate the role of fine needle aspiration cytology (FNAC) in diagnosis of MSGTs and to explore the cases of cytohistological discrepancies in the study. Materials and Methods: This retrospective study was conducted over a 5-year period on 42 cases of MSGTs. In all the cases, cytology was correlated with histology and cytohistological discrepancies were searched. Sensitivity, specificity, and diagnostic efficacy were calculated using histopathology as gold standard. Results: We diagnosed 27 malignant (64.28%) and 15 benign (35.71%) MSGTs in cytological evaluation. We found two false negative and one false positive case in cytology. Sensitivity, specificity, and diagnostic accuracy of the study were 92.59%, 93.33%, and 92.85%, respectively. Conclusion: FNAC is a minimally invasive and cost-effective procedure with high accuracy (92.85%) in the assessment of MSGTs and helps in the management of benign and malignant tumors.
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BRIEF COMMUNICATIONS Top

Metastasis-associated fibroblasts in oral squamous cell carcinoma: An illusion or a reality p. 690
Anjali P Ganjre
DOI:10.4103/jcrt.JCRT_546_17  PMID:31169242
Fibroblasts at the pre-metastatic site exhibited characteristic trait for creation of metastatic milieu which aid in the formation of distant metastasis, and are called as metastasis associated fibroblasts (MAFs).Array of studies showed that MAF bears similar attributes as that of carcinoma associated fibroblasts present in primary tumor. MAFs showed expression of specific type of molecules and pathways to form required pre-metastatic microenvironment at the distant site. It will be important to unrevealed characteristics features in OSCC so as to help in implicating the new therapeutic strategies.
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Carcinoma buccal mucosa with left axillary lymph node metastasis: First reported case and review of the literature p. 693
Rambha Pandey, Rituparna Biswas, Anirban Halder, Durgatosh Pandey
DOI:10.4103/jcrt.JCRT_49_18  PMID:31169243
Head-and-neck squamous cell carcinomas are tumors with propensity mostly for locoregional spread. The most frequent sites of metastasis include lung, bone, liver, adrenal, heart, and kidney. Distant metastasis to axillary lymph nodes from buccal mucosa cancer is extremely rare. To the authors' knowledge, this is the first case reported where a gentleman who was treated for carcinoma right buccal mucosa developed left axillary lymph node metastasis at 6th year of follow-up.
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Head-and-neck cancer patients beyond 2 years of disease control: Preliminary analysis of intensity-modulated radiotherapy late-effect assessment scale p. 696
Trinanjan Basu, Shikha Goyal, Tejinder Kataria, Deepak Gupta
DOI:10.4103/jcrt.JCRT_1459_16  PMID:31169244
Over a decade of intensity-modulated radiotherapy (IMRT) improved the toxicity profile among head-and-neck cancer patients and also improved the quality of life (QOL). Several parameters' few subjective and few objectives have documented various aspects related to QOL. Patients surviving beyond a certain period will have few unattended concern. A single questionnaire-based evaluation might answer few untouched issues. This brief communication formulated such an indigenous single-institution scale named IMRT late-effect assessment scale (ILEA). The preliminary analysis identified concerns related to dryness of mouth, swallowing habit change, and fear of disease recurrence. Future large-scale prospective evaluation is needed.
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CORRESPONDENCE Top

A mixed radiopaque – radiolucent lesion in the anterior mandible associated with multiple impacted teeth: A radiodiagnostic challenge? p. 700
Gowri Pandarinath Bhandarkar, Kushal Vasanth Shetty, Dinkar Desai
DOI:10.4103/jcrt.JCRT_721_16  PMID:31169245
Desmoplastic ameloblastoma (DA) exhibits important differences in gender, anatomic distribution, radiographic findings, and histologic appearance compared to other types of ameloblastoma. Radiologically, DA is seen either as ill-defined mass containing osteolytic and sclerotic areas or as multifocal radiodense flecks within radiolucent background resembling a honeycomb. The radiographic differential diagnosis includes fibro-osseous lesions such as cemento-ossifying fibroma, fibrous dysplasia, calcifying odontogenic cyst, and chronic sclerosing osteomyelitis. Thus, DA should primarily be included in the differential diagnosis of a mixed radiopaque-radiolucent lesion with diffuse borders in the anterior premolar region of the jaws. This report adds to the literature of mixed radiolucent-radiopaque lesions which may not always be histopathologically diagnosed as a fibro-osseous lesion but could turn out to be a DA. This report also benefits the dental community by cautioning them to be aware of DA that can be associated with multiple unerupted teeth which is quite a rare finding.
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Osteoclastic variant of anaplastic thyroid carcinoma: A case report of rare entity p. 704
Divya Shelly, Divya Gupta, Shashank Mishra, Reena Bharadwaj
DOI:10.4103/jcrt.JCRT_355_16  PMID:31169246
Anaplastic thyroid carcinoma (ATC) is a rare, highly malignant thyroid tumor with dismal prognosis. Osteoclastic giant cell variant of ATC is extremely rare and is characterized by the presence of a large number of multinucleated giant cells resembling osteoclasts. We report here this unusual variant in a 67-year-old female with a history of long-standing goiter of 13 years duration. Histologically, many multinucleated osteoclast-like giant cells were seen accompanying the malignant spindle cell component. Despite extensive sampling, no evidence of differentiated thyroid malignancy could be elucidated.
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Nonkeratinizing squamous cell carcinoma: A rare case report with oral involvement p. 708
Rahul Agrawal, Naresh Kumar, Kanupriya Gupta, Nidhi Gupta
DOI:10.4103/jcrt.JCRT_501_17  PMID:31169247
Transitional cell carcinoma also known as nonkeratinizing carcinoma (NKCa) of sinonasal tract comprises 15%–20% of malignant sinonasal carcinoma. We are reporting the case of 48-year-old male with a history of tooth extraction. A computed tomography was done which showed opacity in the right nasal cavity. Incisional biopsy was taken which revealed NKCa (transitional type). Very few reported cases of this type of malignancy were found. A possible reason could be multiple synonyms such as cylindrical cell carcinoma, Schneiderian carcinoma, and transitional cell carcinoma.
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Primary mucoepidermoid carcinoma of the bulbar conjunctiva p. 712
Bodhisattwa Dutta, Nibedita Biswas, Rumeli Roy, Asit Ranjan Deb
DOI:10.4103/jcrt.JCRT_926_17  PMID:31169248
A 58-year-old male presented with redness for 1 year and dimness of vision for 2 years in his left eye. Excision biopsy from an inferotemporal conjunctival mass revealed high-grade mucoepidermoid carcinoma (MEC) with lymphovascular invasion and positive margins. The tumor bed was irradiated to 80 Gy using strontium 90 β-applicator. After 13 months, fine-needle aspiration cytology from a suspicious preauricular lymphadenopathy found metastatic cells. Ipsilateral supra-omohyoid neck dissection showed three positive nodes out of 15, and the left neck was irradiated. He is disease free at present, 12 months from external beam radiation therapy completion. With 48 cases reported in the literature, conjunctival MEC remains a rare condition, possibly in part due to clinicopathological underdiagnosis. This is unfortunate, given that this cancer is more aggressive, has a poorer prognosis, and warrants more vigorous treatment than squamous cell carcinoma, which it may be misdiagnosed as in the absence of appropriate staining and pathological review.
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Ameloblastic fibro-odontoma in a 14 year old girl: A case report p. 715
A Jacob Prakash Rao, Madhusudhan Reddy, Vijaya Lakshmi Mahanthi, K Venkata Chalapathi
DOI:10.4103/jcrt.JCRT_215_17  PMID:31169249
Ameloblastic fibro-odontoma (AFO) is a benign, epithelial odontogenic tumor with odontogenic mesenchyme having the histologic characteristics of both ameloblastic fibroma and complex odontoma. This report describes the case of a 14-year-old girl with AFO on the right posterior mandibular region that mimics complex odontoma on incisional biopsy due to the presence of atypical dentin- and cementum-like areas. On histological examination, sections of excisional biopsy showed odontogenic epithelial islands with embryonic connective tissue and decalcified sections showed atypical dentin with dentinal tubules and islands of cementum. These features led to the diagnosis of AFO.
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Solitary fibrous tumor of the orbit: Computed tomography and histopathological findings p. 719
Asli Tanrivermis Sayit, Muzaffer Elmali, Adem Gul, Yurdanur Sullu
DOI:10.4103/jcrt.JCRT_1194_16  PMID:31169250
A solitary fibrous tumor is a rare spindle cell neoplasm originating from the mesenchyme. This type of tumor of the orbit is very uncommon and can be misdiagnosed as a hemangiopericytoma, fibrous histiocytoma, meningioma, or neurofibroma. We report an orbital solitary fibrous tumor in an 18-year-old male, with slow-growing swelling in the right orbital region. An orbital contrast-enhanced computed tomography scan showed heterogeneously enhancing right extraconal inferomedial mass, with no evidence of calcification or bone destruction. The lesion was surgically excised without complications. Based on microscopic and immunohistochemical findings, the mass was finally diagnosed as a solitary fibrous tumor. These tumors should be preoperatively differentiated from other spindle cell tumors of the orbit, and radiological imaging methods are useful in the differential diagnosis but are nonspecific. Therefore, histopathological and immunohistochemical staining features are more useful for the diagnosis of solitary fibrous tumors, especially CD34 staining.
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A rare case: Branch retinal vein occlusion associated with the use of tamoxifen Highly accessed article p. 722
Nebi Serkan Demirci, Gokmen Umut Erdem, Nil İrem Uçgun, Yakup Bozkaya, Nuriye Yildirim Ozdemir, Mutlu Dogan, Nurullah Zengin
DOI:10.4103/0973-1482.204888  PMID:31169251
Tamoxifen-induced ocular complications including cataracts, keratopathies, retinopathy, impaired visual acuity, ocular irritation, optical neuritis, and retinal vein occlusion are uncommonly reported in the literature. Herein, we report on a premenopausal patient with right-side breast carcinoma who received adjuvant tamoxifen therapy (20 mg/day) for 1.5 years and developed sudden visual loss. Fundal examination revealed an obstruction in the branch of the retinal vein. The diagnosis was confirmed by fluorescein angiography and optical coherence tomography. Thus, tamoxifen was switched to an aromatase inhibitor. Tamoxifen-induced ocular complications should be kept in mind when visual symptoms are seen in patients undergoing tamoxifen therapy. In such cases, a complete ocular examination should be performed.
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Inflammatory myofibroblastic tumor of the oral cavity: A case report and literature review p. 725
Subraj J Shetty, Treville Pereira, Rajiv S Desai
DOI:10.4103/jcrt.JCRT_1044_16  PMID:31169252
Inflammatory myofibroblastic tumor (IMT) is a rare tumor of unknown etiology and pathogenesis. The lesion has been recognized to occur at various sites but rarely affects the head and neck region. A 29-year-old male presented with a 13 months' history of a slow growing, painless growth in maxillary left posterior gingiva. An excisional biopsy was performed under local anesthesia. Microscopic examination revealed a compact cellular spindle cell proliferation with collagenous stroma having storiform architecture. Immunohistochemistry revealed that the tumor cells were positive for smooth muscle actin, CD-68 and negative for anaplastic lymphoma kinase. Oral IMT should be included in the differential diagnosis of localized gingival enlargement mimicking oral hyperplastic/reactive lesions.
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Hemangiopericytoma of supraglottis: A rare case report and review of literature p. 729
Pradip Kendre, Pritam Kataria, Apurva A Patel, L Gaurav, Sameer Dalsaniya
DOI:10.4103/jcrt.JCRT_939_16  PMID:31169253
In 1942, Stout and Murray first used the term hemangiopericytoma to describe a tumor which is distinguished histologically from other types of vascular neoplasm characterized by proliferation of pericytes. It is a rare neoplasm that was originally described as a vascular tumor derived from the pericytes. They account for 2%–3% of all soft tissue sarcomas in humans and they occur mainly in the musculoskeletal system. About 15%-30% of all hemangiopericytomas occur in the head and neck region. Hemangiopericytoma of supraglottis is very rare neoplasm with only nine cases reported in literature and ours is the tenth case overall and first case in pediatric age group. Herein, we are presenting an extremely rare case report of hemangiopericytoma of supraglottis in a 6-year-old male child who presented with stridor followed by which tracheostomy was done. Later, the patient was treated initially with radiotherapy followed by surgery, i.e., laryngectomy in view of residual disease postcurative radiotherapy. Hence, hemangiopericytoma is a very rare tumor overall and can present in pediatric age group and can be one most important differential diagnosis because many patients in this age group, stridor most commonly occurs due to the infectious causes such as influenza virus and diphtheria-induced croup, i.e., laryngotracheobronchitis.
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Rare case of an angiectatic sinonasal polyp feigning malignancy p. 733
Shobha Guntur, Vijendra S Shenoy, K Kshithi, Haneesh Amit Domah, GV Chaithra
DOI:10.4103/jcrt.JCRT_1236_16  PMID:31169254
Angiectatic sinonasal polyps are uncommon. However, riveting nature of this polyp lies in its clinical presentation mimicking a neoplasm. It is radiologically very challenging to pick up this lesion in spite of its characteristic findings on imaging. Histopathology is paramount for asserting diagnosis. We report a rare case of a patient who presented to our outpatient department with chief complaints of nasal block, nasal discharge, and epiphora for 6 months. On examination, a mass was found filling the left nasal cavity. Computed tomography scan and diagnostic nasal endoscopy were suggestive of fungal sinusitis or sinonasal malignancy as a differential diagnosis. Biopsy was reported as benign sinonasal polyp. The patient underwent endoscopic resection of the mass, which on histopathology revealed the diagnosis of an angiectatic sinonasal polyp.
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Synchronous double malignancy of lip and submandibular salivary gland with rare histology p. 737
C Danny Darlington, S Carbin Joseph, G Fatima Shirly Anitha
DOI:10.4103/jcrt.JCRT_270_17  PMID:31169255
In the modern era, there is an increase in the incidence of double malignancies owing to the remarkable improvement in cancer diagnostics and patient survival. Double malignancies can be either synchronous or metachronous. Synchronous double malignancy can present either at the same time or within 6 months of diagnosis of the first one. We present a case of double malignancy of lip and submandibular salivary gland, diagnosed in a 55-year-old male, who presented with ulceroproliferative lesion of the upper lip and a hard swelling in the right submandibular gland. The tissue diagnosis was suggestive of squamous cell carcinoma of the lip and mucoepidermoid carcinoma of the submandibular gland. The patient underwent successful wide local excision of the lip and submandibular gland along with prophylactic supraomohyoid neck dissection. This case is reported for the rarity in site and histopathology of double malignancy.
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LETTER TO THE EDITOR Top

Oral cancer: Etiology and risk factors p. 739
Inci Rana Karaca, Dilara Nur Ozturk
DOI:10.4103/jcrt.JCRT_375_17  PMID:31169256
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