Association of Toll-like receptor 4 with hepatitis A virus infection in Assam

Hepatitis A virus (HAV) which causes liver disease is recognized by Toll-like receptors (TLRs) through the viral nucleic acid, initiating the host defense response. The study aims to analyze the role of TLR4 rs11536889 polymorphism in the pathogenesis of hepatitis A cases from Assam. There was significant correlation between TLR4 SNP G/C (rs11536889) and between acute viral hepatitis (AVH) A cases and controls. The correlation of the 3 different genotypes GG, GC and CC of TLR4 rs11536889 with the TLR4 mRNA expression level in all the HAV cases groups have been found to be statistically significant (p <0.001). TLR4 expression was most significantly upregulated in the acute HAV cases, HAV with cholestasis cases and even the HAV caused fulminant hepatitis failure (FHF) cases with the CC genotype of TLR4 rs11536889. The upregulation is mostly seen in the cases with the CC genotype of TLR4 rs11536889 and thus indicates that the mutant variant of TLR4 rs11536899 (CC) may have an effect on the expression of TLR4 at the transcription level. Our study did not show any significant association between AVH and HAV caused FHF (p = 0.32, OR = 0; p = 0.59, OR = 2.06 at 95% CI) among the genotypes GG, GC and CC. Our data suggest that TLR4 gene polymorphism rs11536889 may play a prominent role in HAV disease susceptibility and TLR4 expression in population from Assam.

RANTES levels as a determinant of falciparum malaria severity or recovery

The study explored the role of differential RANTES concentrations, its receptor CCR5 expression and resulting immunomodulation in the pathogenesis and/or recovery from falciparum malaria. The study population included cases of uncomplicated malaria (UC-M, N=128, enrolled on follow-up basis), severe malaria (SM, N=25), and healthy controls (N=112). Serum RANTES and TNF-α levels were evaluated by ELISA. Monocyte levels and activation profile were studied by flow cytometry. Differential mRNA expression profile was studied by real-time PCR. Blood parasite count was evaluated by registered pathologists. RANTES concentration was significantly downregulated in SM cases compared to UC-M (P=.046) and controls (P<.001). Expression of monocyte marker mCD14, activation markers CCR5 and CD40, and downstream effector cytokine TNF-α was significantly higher in malaria cases compared to controls, in SM cases compared to UC-M. TNF-α expression correlated positively with CD40 and CCR5 expressions. Follow-up-based analysis showed that RANTES concentrations increased on recovery compared to baseline in UC-M cases (P=.106) and inversely correlated with malaria parasite load, mCD14, CCR5 and CD40, and TNF-α expressions. These findings suggest an important association of RANTES concentrations in Plasmodium falciparum malaria disease pathogenesis, as well as recovery, mediated through differential modulation and regulated activation of monocytes and cytokine TNF-α.

Disseminated cysticercosis: role of whole body Magnetic Resonance Imaging

Cysticercercosis is a parasitic infection that is commonly seen in developing countries. Treatment of cysticercosis can precipitate an intense inflammatory response which may further worsen the symptoms. Whole body MRI is an upcoming tool for screening of diseases. It can be acquired in the same setting as a brain MRI in reasonable time without any additional hardware. We present a case wherein whole body MRI was used to evaluate disseminated cysticercosis. It can prove as useful screening tool to gauge the disease load and modify the treatment plan accordingly, especially in endemic areas.

KEY WORDS

disseminated cysticercosis, whole body MRI.

Internal target volume for post-hysterectomy vaginal recurrences of cervical cancers during image-guided radiotherapy

OBJECTIVE

The outcome of post-surgical recurrences of cervical cancer may be improved through radiation dose escalation, which hinges on accurate identification and treatment of the target. The present study quantifies target motion during course of image-guided radiotherapy (IGRT) for vault cancers.

METHODS

All patients underwent planning CT simulation after bladder-filling protocol. A daily pre-treatment megavoltage CT was performed. All translations and rotations were recorded. Post-registration displacement of gross tumour volume (GTV) and centre of mass (COM) of GTV was independently recorded by two observers for fractions one to seven. Day 1 image sets served as reference images against which the displacements of COM were measured. We calculated the displacements of common volume (CV) and encompassing volume (EV) of GTV for both the observers.

RESULTS

A total of 90 image data sets of 15 patients were available for evaluation. Individual patient GTV and average GTV by both the observers were comparable. The average shifts for EV were 2.4 mm [standard deviation (SD) ±1.2] in the mediolateral, 4.2 mm (SD ±2.8) in the anteroposterior and 4.0 mm (SD ±2.1) in superoinferior directions. Similarly, the average shifts for CV were 1.9 mm (SD ±0.6) in the mediolateral, 3.7 mm (SD ±2.7) in the anteroposterior and 4.4 mm (SD ±2.7) in superoinferior directions. Using Stroom's/van Herk's formula, the minimum recommended margins would be 4.5/5.2, 8.2/9.4 and 7.3/8.3 mm, respectively, for lateral, anteroposterior and superoinferior directions.

CONCLUSION

Differential directional internal margin is recommended in patients undergoing IGRT for post-surgical recurrence of cervical cancers.

ADVANCES IN KNOWLEDGE

Internal organ motion of vault cancers can be accounted for by a directional margin to the gross tumour.

Genetic variants of heat shock protein A1L2437 and A1B1267 as possible risk factors for hepatocellular carcinoma in India

To study the role of heat shock protein A1L (HSPA1L) and A1B (HSPA1B) polymorphisms and subsequent risk of hepatocellular carcinoma (HCC) in India. Subjects enrolled included 185 cases of HCC, 182 cases of chronic hepatitis (CH) and 200 healthy controls. Genomic DNA was typed for HSPA1L2437 and HSPA1B1267 SNP using polymerase chain reaction with restriction fragment length polymorphism. Other risk factors were also analysed. Hepatitis B virus (HBV) infection, older age >35 years and high aflatoxin level in urine increased the risk of HCC. The frequencies of HSPA1L BB genotype and B allele in HCC were more than in CH [odds ratio (OR): 9.83; P = 0.000], but also in HBV-related HCC than Chronic Hepatitis B (CHB) [OR: 3.44; P = 0.004] and HCV-related HCC compared to CHC [OR: 6.32; P = 0.010]. The frequency of HSPA1B genotype in the homozygous state was more in CH [OR: 6.01; P = 0.001] and is a good marker to predict the risk of HCV-related CH (CHC) compared to controls. HCV-related HCC has a higher frequency of the B allele of HSPA1B than healthy controls [OR: 3.95; P = 0.000] and CHC [OR: 2.35; P = 0.000], respectively. The frequencies increased further significantly in CHC compared to healthy controls [OR: 9.26; P = 0.000]. The risk for the development of CH and HCC compared to healthy controls irrespective of the aetiology was significant in terms of the HSPA1B marker than HSPA1L in the Indian population.

Evaluation of diffusion-weighted imaging as a predictive marker for tumor response in patients undergoing chemoradiation for postoperative recurrences of cervical cancer

PURPOSE

To investigate diffusion-weighted imaging (DWI) as a response biomarker in patients undergoing chemoradiation for postoperative recurrences of cervical cancer.

MATERIALS AND METHODS

From October 2008 to March 2011, 20 patients were included. All underwent T2-weighted (T2W) and DWI before and after chemoradiation. Gross tumor volume (GTV), lateral extent, apparent diffusion coefficient (ADC), and presence of regions of focally restricted diffusion were determined at baseline. Response to chemoradiation was categorized as either partial or complete. Receiver operator characteristics (ROC) curve identified thresholds of GTV and ADC that best predict for partial response. Univariate and multivariate analysis were performed on SPSS version 15.

RESULTS

The median GTV was 24.5 cc (4.1-110 cc). Central and lateral disease was present in 8 and 12 patients, respectively. The median ADC was 1 × 10 -3 mm² /s (0.8-1.3 × 10⁻³ mm² /s) and 12/20 (60%) patients had focal restricted diffusion. Overall 10/20 patients had partial response. ROC analysis identified volume of 25 cc or higher [sensitivity = 80%, specificity = 80%, area under curve (AUC) = 0.76, P = 0.04] and ADC more than 1 × 10⁻³ mm² /s (sensitivity = 70%, specificity = 50%, AUC = 0.62; P = 0.34) to best predict for partial response. On univariate analysis bulky disease (77.7% vs. 27%; P = 0.03), lateral disease (66.6% vs. 25%; P = 0.08), and focal regions of restricted diffusion (66.6% vs. 25%; P = 0.06) predicted for partial response to chemoradiation. All factors continued to be significant on multivariate analysis. On restricting analysis to bulky tumors ADC greater than 0.95 × 10⁻³ mm² /s predicted partial response with high sensitivity (85.7%) and specificity (100%) (AUC 0.96; P = 0.05). On univariate analysis lateral disease (P = 0.04), high baseline ADC (P = 0.07) predicted for partial response.

CONCLUSIONS

Baseline ADC and focal regions of ADC restriction predict for partial response with moderate sensitivity and specificity in patients with postoperative recurrences of cervical cancer and need to be validated in larger cohort.

Inter and intraobserver variation in gross tumor delineation on megavoltage CT images in patients undergoing tomotherapy-based image-guided radiotherapy for postoperative vault recurrences

PURPOSE

This study was designed to evaluate inter and intraobserver concordance in gross tumor volume (GTV) delineation on megavoltage CT (MVCT) images in patients with postoperative vault recurrences.

MATERIALS AND METHODS

Three observers delineated GTV on MVCT and CECT and two observers recontoured on MVCT images. Tumor volumes were calculated and correlated using Spearman correlation. The standard deviation of centre of mass was averaged on per patient basis. The ratio of common volume and encompassing volume was used to determine intra and interobserver spatial concordance. Lack of difference in spatial concordance ratio between MVCT and CECT images was used as an index of usability of MVCT images.

RESULTS

Thirty six datasets were available for seven patients. High intraobserver GTV correlation was recorded for observer 1 and 2 (r = 0.93 and r = 0.98; P=0.03 and 0.0001). The average intraobserver spatial concordance ratio was 0.57 and 0.62 respectively. The mean GTV of observers 1, 2 and 3 were 31.6 (18.7-52.2); 28.2 (16.7-51.8) and 46.3 cc (29.1-90.5) respectively. Average standard deviation of centre of mass of all observers was less than 5 mm in either direction. Largest interobserver discordance was observed in anterior, inferior and lateral direction. The interobserver spatial concordance of GTV on MVCT and CECT images was 0.34 and 0.36 (P=0.24) respectively.

CONCLUSION

Moderate to good inter and intraobserver GTV correlation was observed on MVCT images, however, was associated with low interobserver spatial concordance on both MVCT and CECT images. Strategies to improve contouring reproducibility on MVCT and KVCT images are desirable.

Successful management of multi-focal hepatic infantile hemangioendothelioma using TACE/surgery followed by maintenance metronomic therapy

Infantile hepatic hemangioendothelioma (IHE) is a rare angiogenic tumour with diverse clinical presentations and varied course ranging from spontaneous regression to life-threatening complications. The authors report a 2-year boy who presented with respiratory distress and was identified as a case of inoperable multi-focal hepatic IHE. He showed a transient response to trans-arterial-chemo-embolisation and liver resection but had progressive disease despite chemotherapy (prednisolone/vicristine/ifosfamide/cisplatin). Thereafter, he was successfully managed with metronomic therapy using cyclophosphamide and tamoxifen.

Bilateral renal metastases in a case of Merkel cell carcinoma

Merkel cell carcinoma is a primary neuroendocrine carcinoma of the skin. It is a highly aggressive tumor which commonly metastasizes to lymph nodes, liver, lung and bone. The diagnosis is based on histology and immunohistochemistry. Renal metastasis, with sparing of other common sites of hematogenous spread (lung and liver), is a unique feature of this case.

Prognostic factors and outcome in Askin-Rosai tumor: a review of 104 patients

PURPOSE

To evaluate the prognostic factors and treatment outcome of patients with Askin-Rosai tumor of the chest wall treated at a single institution.

METHODS AND MATERIALS

Treatment comprised multiagent chemotherapy and local therapy, which was either in the form of surgery alone, radical external-beam radiotherapy (EBRT) alone, or a combination of surgery and EBRT. Thirty-two patients (40%) were treated with all three modalities, 21 (27%) received chemotherapy and radical EBRT, and 19 (24%) underwent chemotherapy followed by surgery only.

RESULTS

One hundred four consecutive patients aged 3-60 years were treated at the Tata Memorial Hospital from January 1995 to October 2003. Most (70%) were male (male/female ratio, 2.3:1). Asymptomatic swelling (43%) was the most common presenting symptom, and 25% of patients presented with distant metastasis. After a median follow-up of 28 months, local control, disease-free survival, and overall survival rates were 67%, 36%, and 45%, respectively. Median time to relapse was 25 months, and the median survival was 76 months. Multivariate analysis revealed age ≥18 years, poor response to induction chemotherapy, and presence of pleural effusion as indicators of inferior survival. Fifty-six percent of patients with metastatic disease at presentation died within 1 month of diagnosis, with 6-month and 5-year actuarial survival of 14% and 4%, respectively.

CONCLUSION

Primary tumor size, pleural effusion, response to chemotherapy, and optimal radiotherapy were important prognostic factors influencing outcome. The combination of neoadjuvant chemotherapy, surgery, and radiotherapy resulted in optimal outcome.

Primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old woman: a case report

Introduction

Primary Ewing's sarcoma or primitive neuroectodermal tumor of the genital tract of women is uncommon. Rarer still is its occurrence in the vagina, with only five cases described so far. Out of these, only one case was confirmed using molecular analysis.

Case presentation

We present an extremely rare case of Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old Indian girl. She presented with a vaginal mass that was initially diagnosed as a malignant round cell tumor. Immunohistochemistry showed diffuse positivity for vimentin, membranous positivity for MIC2, and positivity for BCL2 and FLI-1. On the other hand, she was negative for cytokeratin, epithelial membrane antigen, desmin, Myo D-1, myogenin and smooth muscle actin. A diagnosis of primitive neuroectodermal tumor was thus offered. Furthermore, a molecular analysis of our patient using reverse transcription-polymerase chain reaction technique showed positivity for t(11; 22) (q24; q12) (EWSR1-FLI1), thus confirming the diagnosis of a Ewing's sarcoma/primitive neuroectodermal tumor. Our patient was offered chemotherapy on Institutional protocol EFT 2001.

Conclusion

This is a rare case of primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor, which was confirmed with molecular analysis, in the youngest patient known so far. This study reinforces the value of integrating morphological features with membranous MIC2 positivity, along with application of molecular techniques in objective identification of an Ewing's sarcoma or primitive neuroectodermal tumor at uncommon sites.

MRI findings of cerebral malaria. A report of two cases

Cerebral malaria is a protozoal disease affecting the brain caused by Plasmodium falciparum. The hallmark of cerebral malaria is progressive decline in the sensorium leading to coma and in some cases death. MR findings reported in cerebral malaria are diffuse cerebral swelling / edema, bilateral nearly symmetrical T2 hyperintense lesions in basal ganglia and similar lesions in thalamus, pons and cerebellum. The imaging findings of cerebral malaria depend on the duration of the illness and time of MR examination. We describe two patients of cerebral malaria having mixed Plasmodium falciparum and Plasmodium vivex infestation showing bilateral basal ganglia infarcts with cerebral swelling in one patient and bilateral basal ganglia and cerebellar lesions in the other.

18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/computerized tomography study

Leptomeningeal metastases (LM) are most commonly observed in hematological malignancies. With prolonged survival in solid tumors, an increased frequency of metastases is noted in these tumors too. Early diagnosis, when the patient has minimal neurological disability, is associated with prolonged survival and improved functional outcome although the therapy is palliative. The diagnosis of LM is difficult, and the demonstration of tumor cells in the cerebrospinal fluid remains the gold standard. This can also be done by definitive neuroimaging. MRI is routinely used in this aspect. We discuss here a case where 18F-FDG PET/CT (Fluoro-de-oxy glucose positron emission tomography/computerized tomography) study helped us in the diagnosis of LM. Whole-body PET/CT imaging could be a useful tool in identifying the possibility of metastases of breast carcinoma in the usual sites and the not-so-usual sites of metastases.

Six-hour window of opportunity for calpain inhibition in focal cerebral ischemia in rats

BACKGROUND AND PURPOSE

Stroke patients often experience a significant temporal delay between the onset of ischemia and the time to initiation of therapy. Thus, there is a need for neuroprotectants with a long therapeutic window of opportunity. The efficacy of a potent, central nervous system-penetrating calpain inhibitor (MDL 28,170) was evaluated in a temporary model of focal cerebral ischemia to determine the window of opportunity for intracellular protease inhibition.

METHODS

An ex vivo brain protease inhibition assay established pharmacodynamic dosing parameters for MDL 28,170. Middle cerebral artery (MCA) occlusion was accomplished by advancing a monofilament through the internal carotid artery to the origin of the MCA. Postmortem infarct volumes were determined by quantitative image analysis of triphenyltetrazolium-stained brain sections.

RESULTS

Maximal inhibition of brain protease activity was observed 30 minutes after injection of MDL 28,170 with an estimated pharmacodynamic half-life of 2 hours. MDL 28,170 caused a dose-dependent reduction in infarct volume when administered 30 minutes after MCA occlusion. A window of opportunity study was conducted to determine the maximal delay between the onset of ischemia and the initiation of efficacious therapy. MDL 28,170 reduced infarct volume when therapy was delayed for 0.5, 3, 4, and 6 hours after the initiation of ischemia. The protective effect of MDL 28,170 was lost after an 8-hour delay.

CONCLUSIONS

These data indicate that the therapeutic window of opportunity for calpain inhibition is at least 6 hours in a reversible focal cerebral ischemia model. This protection is observed despite the lethal hypoxic and excitotoxic challenge, suggesting that calpain activation may be an obligatory, downstream event in the ischemic cell death cascade.