Anshul Singh

Endoscopic repair of cerebrospinal fluid rhinorrhea - Manipal experience

Otolaryngologists play a major role in the management of cerebrospinal fluid (CSF) rhinorrhea. A thorough understanding of the underlying pathophysiology and the various treatment options available is essential to achieve the best possible results.In this paper, we are highlighting the pathophysiology, diagnosis and surgical technique involved in the repair of cerebrospinal fluid rhinorrhea. A retrospective study conducted in the department of ENT and Head and Neck Surgery, Kasturba Hospital, Manipal is presented to highlight our experience with cerebrospinal fluid rhinorrhea.Eleven patients were managed in the department of otolaryngology between 1999 and 2005. Seven had spontaneous CSF rhinorrhea, three were due to trauma and one iatrogenic, following surgery. Commonest anatomic site of leak was the cribriform plate in 4 cases. Other sites included sphenoid [2], lateral lamella [2], fovea ethmoidalis [2] and olfactory groove [1]. Onlay technique was performed in 10 out of 11 patients. Closure was successful in 10 out of 11 cases in the first attempt. One patient underwent revision surgery. Patients were followed up for a period ranging from 3 months to 3 years.CSF rhinorrhea is a potentially fatal condition which requires precise and urgent treatment. The transnasal endoscopic repair of CSF leak has a high success rate with low morbidity when performed by experienced endoscopic sinus surgeons. Our experience in managing this condition is presented.

A Study on Dosimetric Outcomes and Acute Toxicity of Post Mastectomy Adjuvant Hypofractionated Radiotherapy for Breast Cancer.

INTRODUCTION Hypofractionated External Beam Radiotherapy (HFRT) is a relatively new adjuvant Radiotherapy (RT) schedule for breast cancers following breast conservation surgery and less commonly, following mastectomy. Here we report our experience on normal tissue exposure and acute toxicity of HFRT after mastectomy. AIM To assess the dosimetric outcomes and acute toxicity profile of adjuvant HFRT following mastectomy for breast cancer. MATERIALS AND MATERIALS This prospective observational study considered consecutive patients planned for adjuvant HFRT (42.5 Gy in 16 sessions delivered over 3 weeks) to the chest wall with/without regional nodes between October 2014 and June 2015. The dosimetric parameters including dose homogeneity to the target volume and exposure to heart and lung were analyzed. Acute haematological and dermatological toxicity was recorded until upto three months after completion of RT. RESULTS Among the 56 patients treated with HFRT, the mean age was 49 years (range: 28-69 years). Pathologically positive nodes and ≥pT3 primary was observed in 44 (78.6%) and 12 (21.4%) patients, respectively. Majority (87.5%) received prior adjunct chemotherapy. RT to the supraclavicular fossa was delivered for 39 (69.6%) patients. The mean V90 and V95 to the Planning Target Volume (PTV) were 95% (± 3.3%) and 93% (± 4%), respectively. The maximum dose received was on average 47.7 Gy (112%; range: 46.2-48.5 Gy). The mean lung dose was 10.2 Gy (± 3.5 Gy) and V20 was 20.9% (± 6%). The mean V25 to heart was 6.6% (± 4.8%) for left sided and 0% for right sided tumours (p=0.001). Acute skin toxicity peaked at completion of RT and was tolerable (grade 0, I, II and III reactions were 75%, 16% and 1.8%, respectively). No patient had ≥ grade III haematological toxicity, and treatment was not interrupted for any patient. CONCLUSION Adjuvant HFRT could be planned while meeting the dose constraints to normal tissues in all patients and was well tolerated, with mild to moderate acute adverse effects that did not warrant any therapeutic intervention or treatment interruption.

Detection of human papilloma virus in patients with squamous cell carcinoma of the esophagus planned for definitive chemo-radiotherapy, and a study of their clinical characteristics

CONTEXT To identify the incidence of human papilloma virus (HPV) infection in squamous esophageal cancer. AIMS To identify high-risk (HR) HPV positivity rates in patients with squamous carcinoma esophagus and to compare their characteristics with HPV negative counterparts. SETTINGS AND DESIGN A prospective study, in which tumor biopsies of 18 consecutive patients with squamous carcinoma of the esophagus treated with definitive chemo-radiotherapy (CT-RT) were evaluated for the presence of HPV. SUBJECTS AND METHODS Tumor biopsies of 18 consecutive patients with squamous carcinoma esophagus treated with definitive CT-RT were assessed for presence of HR HPV DNA by hybrid DNA capture technique (Digene-HC2). The clinical characteristics and treatment outcomes of the two groups were then compared. STATISTICAL ANALYSIS USED Pearsons Chi-squared test, Kaplan-Mier survival curve/log rank test. RESULTS Nine patients (50%) tested positive for HR HPV. The clinical features including age, gender, grade, location, and tumor extent were similar between the two groups. All the three patients with residual disease at the end of treatment tested positive for HPV (P = 0.058). At a mean follow-up of 52 weeks, the estimated median recurrence free survival was 37 weeks (95% confidence interval (CI): 13.6-60.4) among HPV positive patients compared to 53 weeks (95% CI: 29.6-76.4 weeks) for the HPV negative (P = 0.93). CONCLUSIONS There appears to be a high incidence of HPV among patients with squamous oesophageal cancer in coastal Karnataka. Further studies are required to evaluate its causative role and prognostic implications.

Bilateral primary adrenal lymphoma successfully treated with non-CHOP chemotherapy regimen

Primary bilateral non-Hodgkin’s lymphoma of the adrenal gland is a rare presentation with <200 reported cases. We report a 70-year-old man who presented with vomiting and abdominal pain for 2 weeks and was subsequently diagnosed to have high-grade lymphoma of the adrenal glands. The patient was then started on a rituximab–bendamustine chemotherapy regimen. The patient tolerated treatment well without significant side effects. Repeat positron emission tomography CT scan after four cycles of chemotherapy showed complete response. The patient has completed six cycles of chemotherapy and is on regular follow-up with no signs of relapse.

Unresectable squamous cell carcinoma of upper trachea with long-term survival after concurrent chemoradiotherapy

Upper tracheal malignancies are rare, and long-term survival is even rarer, especially among the unresectable malignancies. A 66-year-old chronic smoker was diagnosed as a locally advanced, non-metastatic squamous cell carcinoma of the upper trachea. Being unresectable, he was treated with six cycles of concurrent weekly cisplatin and three-dimensional conformal radiotherapy to a dose of 60 Gy in 30 fractions over 6 weeks. Follow-up imaging at 6 and 12 months revealed no disease. Our patient is presently 36 months post-treatment and is disease free without tracheal necrosis, fistula or radiation pneumonitis but developed hypothyroidism and is presently euthyroid. Concurrent chemoradiotherapy appears safe up to 3 years at least without any necrosis and is effective in controlling local disease. Meticulous planning obviates the need for higher technology like motion management techniques or intensity-modulated radiotherapy.

Is cholesteatoma a precursor of verrucous carcinoma: A diagnostic dilemma

Verrucous carcinoma is an unusually well-differentiated variant of squamous cell carcinoma, characterized by local invasion and cytologically benign appearance. We report a case of 52-year-old male who presented with postauricular growth and cholesteatoma in the right ear. High-resolution computed tomography temporal bone showed an enhancing soft tissue mass lesion extending into the mastoid, external auditory canal, and middle ear. Growth was histopathologically confirmed to be verrucous carcinoma extending from the cholesteatoma in mastoid cavity. Review of literature confirms the rarity of cases of cholesteatoma which could progress and present as verrucous carcinoma in the postauricular region.