NUTRITION ASSESSMENT IN HEAD AND NECK CANCER PATIENTS PRE and POST CHEMORADIOTHERAPY.

INTRODUCTION: Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment. Deterioration of the nutritional status results in an increase in chemo radiotherapy related toxicity and this may increase the prolonged treatment time, which has been associated with poor clinical outcome. The present study aims to do nutritional assessment before and after chemo radiotherapy in head and neck cancer patients. MATERIAL AND METHODS: The present study was undertaken at the Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly. In this study, 50 patients of Head and neck tumours were enrolled and their nutrition was assessed before and after chemoradiotherapy. Nutrition assessment was done using different laboratory parameters like haemoglobin, total leukocyte count, blood urea, serum creatinine and serum bilirubin. Anthropometric parameters used are Body mass index, Skin fold thickness, and Mid-arm circumference. Nutritional risk indicator and PG-SGA score is measured before and after chemoradiotherapy. All the parameters were assessed and analysed using different statistical tests- Chi-square test, Fisher Exact test and paired t test.RESULTS: Haemoglobin decrease was statistically significant during treatment (p less than 0.001) and the decrease in total leukocyte count during treatment was showing trend towards significance (p value-0.056). There was deterioration in other parameters like blood urea, serum creatinine and serum bilirubin but was not statistically significant. Anthropometric parameters- Body mass index, mid-arm circumference and skin fold thickness and percent body fat showed a significant change (p less than 0.00001). Nutritional risk indicator and PG-SGA class has decreased for majority of patients during treatment, the change is statistically significant (p less than 0.00001 and p=0.0251) respectively.CONCLUSION: The nutrition has important role to play in the management of head and neck cancers by chemo radiotherapy. It helps to reduce the complications and improve the tolerance of chemo radiotherapy, thus avoiding treatment breaks which may lead to failure of treatment.

COMPUTED TOMOGRAPHY CORRELATION OF THORACIC LESIONS WITH TRANSTHORACIC FINE NEEDLE ASPIRATION CYTOLOGY AND BIOPSY

INTRODUCTION: The study is an attempt to evaluate the sensitivity, specificity, positive predictive value, negative predictive value, p Value and complications of CT guided thoracic interventions fine needle aspiration cytology and core biopsy which are used for diagnosing benign and malignant thoracic lesions. MATERIAL AND METHODS: Study included 102 Patients (87 males and 15 females) with age group ranged from 15 to 87 years.A total of 143 CT guided interventions (84 FNAC’s and 59 core biopsies) were performed in 102 patients. The tissue obtained was sent to the laboratory for histopathological and cytological analysis for a final diagnosis which would contribute to patient management. RESULTS: All( 59) core biopsies were successful in procuring adequate tissue for histopathological analysis and the yield of core biopsies was 100% .However out of 84 FNAC’s only 4 were unsuccessful in procuring adequate tissue with a failure rate of 4.8%. Post procedural biopsy complications were only three (2.1%) which were small pneumothorax. There were 75 malignant lesions and 23 benign lesions based on cytology and histopathology (4 were excluded due to inadequate sample). There was good agreement between benign and malignant lesions diagnosed on CT and that diagnosed by pathology. The most common benign and malignant lesions were granulomatous lesion and squamous cell carcinoma. CONCLUSION: Percutaneous CT guided interventions like core biopsy and fine needle aspirations cytology are simple minimal invasive procedures with good patient acceptance and low morbidity and almost negligible mortality. CT guided interventions should be performed early for diagnosis of thoracic lesions.

TO STUDY THE FETO-MATERNAL OUTCOME IN OCCIPITO-POSTERIOR POSITION.

INTRODUCTION: Childbirth is considered as one of the most rewarding and memorable experience in a woman’s life.Labour is the process that leads to childbirth. Difficult labour characterized by abnormally slow labour progress is known as dystocia. Malposition refers to any position of the vertex other than flexed occipito- anterior one. It is a common obstetric belief that progression of labour is underpinned by fetal position. MATERIAL AND METHODS: 100 term antenatal patients, 50 with occipito-posterior and 50 with occipito-anterior position were included in the study admitted in labour room from December 2015 to March 2017. After recuirtment of patients, detailed history, examination: general physical, per abdominal and per vaginal was done. All patients underwent ultrasonography to confirm the fetal position at the onset of labour. They were then followed up until birth to determine outcome. The primary outcome measures including mode of delivery which was categorized into vaginal delivery, instrumental delivery and Cesarean section, duration of labour and neonatal outcome. RESULTS: Of the total 100 cases, the proportion of vaginal delivery was more in occipito-anterior group (74%) in comparison with occipito-posterior group (42%). 40% patients of occipito-posterior group landed into cesarean delivery against 18% patients of occipito-anterior group. Eight percent patients had face to pubis delivery. The mean duration of labour is prolonged in study group i.e. 473.2±1.84 minutes in first stage, 29.4±7.67 minutes in second stage and 5.70±1.75 minutes in third stage versus i.e. 376.8±1.26 minutes in first stage, 24.79±9.77 minutes in second stage and 5.20±3.22 minutes in third stage of labour of control group. The neonatal outcome was analysed by Apgar score at 1,5 minutes of delivery, presence of caput succedaneum and moulding and found to be comparable in both the groups. CONCLUSION: We found that malposition group showed prolongation of labour in comparison to occipito-anterior position. We found high rate of cesarean delivery in study group because of preference for cesarean over instrumental delivery. Neonatal outcome were comparable in both the groups. We noted few instrumental deliveries owing to the fact that art of instrumental delivery is dying in modern obstetrics.

A COMPARATIVE STUDY TO EVALUATE C-REACTIVE PROTEIN AND PROCALCITONIN AS A MARKER OF BACTERIAL INFECTION IN PATIENTS WITH ACUTE EXACERBATION OF COPD.

INTRODUCTION: Exacerbations of COPD can be precipitated by several factors. The most common causes appear to be respiratory tract infections. Overuse of antibiotics is common and accelerates the development of drug resistance and hospital acquired infections. In some recent studies, both C-reactive protein as well as Procalcitonin levels have been shown to be useful in differentiating bacterial etiology of exacerbations and thus helping in guiding the treatment as well as in prediction of outcome. Evaluate sensitivity and specificity of C-reactive protein and Procalcitonin as a marker of bacterial infection in patients with acute exacerbation of COPD. MATERIAL AND METHODS: The present hospital-based observational study was carried out at Department of Pulmonary Medicine, SRMSIMS, Bareilly. 50 patients from patients of COPD with acute exacerbation attending/admitted to Pulmonary OPD/IPD were included in the study excluding those below 40yrs old or presenting with acute breathlessness due to comorbid condition. Demographic information, relevant clinical data and lab investigations were recorded from all patients including C-reactive protein and Procalcitonin on admission following which the patients were started antibiotics as per guidelines. Reassessment of S. Procalcitonin and C-reactive protein was done on 3rd and 7th day of hospitalization. ROC Curve was applied to compare sensitivity and specificity. RESULTS: Sputum culture was found positive in 27 (54.0%) patients. At all the three intervals, CRP levels had ROC area under curve (ROCAUC) values above 0.70. Area under curve value was maximum at day 3. For Procalcitonin, the area under curve values were >0.8 at day 1 and day 3 but on day 7 this value was only 0.624. On evaluating the correlation between S. C-Reactive Protein and Procalcitonin levels, a mild positive and significant correlation was observed at day 1 and day 7 intervals whereas on day 3 a moderate positive and significant correlation was observed between the two markers.CONCLUSION: CRP is good marker when tested early and late while PCT is better when tested early.

APPLICATION OF DECAF AND BAP-65 TO PREDICT THE IN-HOSPITAL MORTALITY OF ACUTE EXACERBATION OF COPD IN SRMSIMS

INTRODUCTION: Hospitalisation due to acute exacerbations of COPD is common, and subsequent mortality high. The DECAF and BAP 65 score was derived for accurate prediction of mortality and risk stratification to inform patient care. We aimed to validate these scores, and to compare them. Comparison of DECAF, BAP-65 scores in predicting in hospital mortality in AECOPD MATERIAL AND METHODS: 106 patients of AECOPD, admitted during 6 months period were scored at admission using all 2 scores and their ability to predict in-hospital mortality was analysed. RESULTS: On receiver-operator characteristic curve analysis, the area under curve for prediction of in-hospital mortality was 0.791and 0.885 respectively for DECAF and BAP-65 scores respectively. Thus, among the two scoring systems BAP-65 had maximum area under curve while DECAF had minimum area under curve. Sensitivity and specificity values for prediction of in-hospital mortality were 83.3% and 54.3% for DECAF and 83.3% and 84.0% for BAP-65. Thus BAP-65 was the best predictor with adequate sensitivity and specificity for the in-hospital mortality.CONCLUSION: BAP-65 was most effective in prediction of in-hospital mortality

WEEKLY VERSUS TRI-WEEKLY CONCURRENT CISPLATIN WITH RADIOTHERAPY IN THE TREATMENT OF CERVICAL CANCER: A STUDY COMPARING EFFICACY AND TOXICITY

INTRODUCTION: Concurrent chemoradiation is the standard treatment for the locally advanced cervical cancer. The optimal Cisplatin dose and dosing schedule are still undetermined. The present study aims to evaluate the efficacy and toxicity of weekly and tri-weekly cisplatin with radiotherapy in treatment of cervical cancer. MATERIAL AND METHODS: Fifty patients with histologically proven Stage IA-IIIB cervical cancer were randomly assigned to weekly (Arm 1, cisplatin 35 mg/m2, five cycles) and tri-weekly (Arm 2, cisplatin 75 mg/m2 every 3 weeks, two cycles) chemotherapy during radiotherapy. The difference of efficacy and toxicity profiles between the two regimens was investigated, and the response rate was analyzed. RESULTS: All patients tolerated both treatments well. There was significantly better chemotherapy compliance in tri-weekly arm (100% vs 68%, p=0.002). Leucopenia was higher in ARM-B then ARM-A (16% vs 4%, p=0.15). Vomiting grade II/III was significantly higher in ARM-B then ARM-A (64% vs 24%, p=0.009). Grade II Genito-urinary toxicity was higher in ARM-B then ARM-A (20% vs 4%, statistically not significant). CONCLUSION: Both weekly cisplatin 35 mg/m2 and tri-weekly 75 mg/m2 concurrent with radiotherapy are equally feasible and efficacious.

ETIOLOGICAL, CLINICAL AND PATHOLOGICAL PROGNOSTIC MARKERS IN HEAD AND NECK CANCERS TREATED WITH CONCURRENT CHEMO-RADIATION

Introduction: Advanced squamous cell carcinoma of head and neck are usually treated with surgery and/or radiotherapy. Integration of chemotherapy also plays an important role for improving organ preservation. Various prognostic factors help in selecting the appropriate treatment regimen for the individual patient. The present study was conducted to identify the prognostic factors in head and neck cancers. Material and Methods: Previously untreated 33 patients of squamous cell carcinoma were selected. They were treated with concurrent chemotherapy and radiotherapy. The response assessment was analyzed in terms of various patient, tumor and treatment related factors. Statistical analysis was done using chi square test. Results: Etiological factors- tobacco and alcohol, non-vegetarean diet were associated with a poor outcome but were not statistically significant. Clinical factors- higher N-stage (p=0.04) and AJCC stage (p=0.03) were found to be significant predictors of poor prognosis while T-stage was not found significant, probably due to short follow-up. Patients receiving less than 5 cycles of concurrent chemotherapy had a significantly worse prognosis (p=0.04). Among the pathological factors that were studied, high mitotic index (Grade III or more) were associated with a significantly poorer prognosis (p=0.04). Conclusion: Many clinico pathological factors have been correlated with locoregional control in head and neck cancers. These can be used to individualize the treatment by different surgical techniques, various radiotherapy dose and fractionation schedules and chemotherapy protocols.

PROSPECTIVE RANDOMIZED STUDY ON TWO DOSE FRACTIONATION REGIMENS OF HIGH DOSE RATE BRACHYTHERAPY FOR CARCINOMA CERVIX: COMPARISON OF CLINICAL RESPONSE AND COMPLICATIONS IN ORGANS AT RISK

Introduction: Cancer Cervix is treated with a combination of external beam radiotherapy and intracavitary brachytherapy. With the recent American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix, at least Equivalent Dose 2 > 80 Gy for patients with complete response or partial response with residual disease less than 4cm is recommended. For non responders or those with tumors larger than 4cm at the time of brachytherapy, tumor dose escalation to an Equivalent Dose 2 of 85-90 Gy is recommended to point A. Present study was designed to see the feasibility of these guidelines in terms of local tumor control and toxicities to rectum and bladder in our group of patients. Material and Methods: Fifty patients of biopsy proven cancer cervix were enrolled. After pre-treatment evaluation all patients were delivered external beam radiotherapy 50 Gy in 25 fractions at 200 cGy/day with concurrent cisplatin on weekly basis. Patients were then randomized into three applications (Group A), four applications (Group B) of HDR Brachytherapy of 6 Gy each so that total treatment time does not exceed 8 weeks. BED and LQED were calculated and assessment of response and complications were assessed. Statistical analysis was done using Chi square test. Results: Mean age of the patients was 50 years. No significant hematological toxicities and radiation reactions were seen during external beam radiotherapy. The mean BED of group A for tumor, rectum and bladder was 137.3 Gy, 112.53 Gy and 103.23 Gy respectively and of group B was 155.3 Gy, 120.98 Gy and 111.95 Gy respectively. The mean EQD2 in group A at tumor, rectum and bladder was 74 Gy, 54.08 Gy and 61.94 Gy respectively and in group B was 82 Gy, 59.18 Gy, and 66.60 Gy respectively. There was no statistically significant difference in local response and early and late bladder reactions in both the groups. Conclusion: In a follow up of six months we did not find any significant difference in toxicities of rectum and bladder. Long term follow up is needed to see for late rectal and bladder toxicities.

LEPROSY WITH PSORIASIS A RARE ISOTOPIC PHENOMENON

Introduction: Isotopic phenomenon refers to the occurrence of a new dermatosis at the site of previously healed dermatosis. A number of factors including viral, neural, vascular, and immunologic factors have been implicated in the causation of this peculiar phenomenon but none has been proven conclusively. We report a case where leprosy developed at the site of psoriatic lesion previously treated with medical therapy. Case Report: A 50 years old male presented with chief complaints of erythematous, mildly itchy scaly lesions all over the body with a history of relapses and remissions for last 20 years. After confirming the diagnosis of psoriasis with leprosy, patient was managed as an inpatient with oral hypoglycemic drugs along with multibacillary multi drug therapy. For psoriasis, patient was prescribed topical corticosteroids along with emollients over thick scaly lesions. Conclusion: This case has been reported due to the rarity of Wolf’s isotopic phenomenon and the coexistence of psoriasis with leprosy. The existing sporadic cases in literature which question the mutually exclusive relationship of leprosy and psoriasis needs further evaluation.

COMPARISON OF STATURE AND FOOT LENGTH IN ADULTS IN SRMS IMS BAREILLY

Introduction: Estimation of stature plays an important role in forensic anthropometry as it helps in estimating the identity of an individual. Many studies for estimating the stature from measuring long bones, with derivation of formulas are there. The present study is an attempt to evaluate a possible correlation between stature of an individual and foot length in adults. Material and Methods: A sample of 100 medical students; 50 males and 50 females studying in Shri Ram Murti Smarak Institute of Medical Sciences was considered and measurements were taken for height and foot length. Result: It was found that both the parameters showed a correlation with each other. Mathematical formulae for estimating stature were developed through basic linear regression. Conclusion: It can be concluded that the present study has provided regression equations for stature and foot length of an individual that can be used for stature estimation.