Paediatric Surgery

ORIGINAL ARTICLES
	Role of laboratory markers in predicting severity of acute appendicitis	p. 1
	Samarth Virmani, Padubidri Santosh Prabhu, PT Sundeep, Vijay Kumar DOI:10.4103/ajps.AJPS_47_16   Background: Accurately differentiating simple and complicated acute appendicitis (CAA) in children preoperatively can be challenging. The aim of this study is to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR), total leukocyte count (TLC), percentage lymphocyte, and percentage neutrophil counts to predict the type of appendicitis a patient has preoperatively and to determine the better indicator among these. Materials and Methods: Record of 233 patients under 18 years of age who underwent appendectomy from 2005 to 2014 was evaluated. Based on perioperative findings of the surgeon, the patients were grouped under categories simple acute appendicitis (SAA) and CAA. Information such as age, gender, and laboratory investigations of the patients were recorded and analyzed. Results: SAA included 185 patients and CAA included 48 patients. An NLR >4.8, TLC >13,500 cells/mm3, percentage lymphocyte count <14.8%, and percentage neutrophil count >75% were found to be associated with complicated appendicitis. The highest sensitivity and specificity among these findings were found with the percentage lymphocyte count, which were 70.8% and 63.8%, respectively. Conclusion: The preoperative percentage lymphocyte count serves as a better indicator than TLC, NLR, and percentage lymphocyte count and is a useful parameter in differentiating simple and complicated appendicitis and can be used as a valuable adjunct to the surgeon's clinical evaluation.
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	Indocyanine green clearance test to evaluate liver function in rat model of extrahepatic biliary atresia	p. 5
	Hemonta Kr Dutta, DN Rao, DK Gupta DOI:10.4103/ajps.AJPS_78_16   Background: Indocyanine green clearance test (ICG-K) has been shown as a sensitive marker of liver function in patients with cirrhosis. However, its role in the assessment of liver function in children with biliary atresia is not well established. The present study was undertaken to evaluate the ICG-K in an experimental model of cholangitis and partial biliary obstruction. Materials and Methods: Thirty albino rats were divided into 3 groups of 10 each. After exploration under anesthesia, a vial of OK-432 diluted in 0.2 ml of normal saline was injected into the common bile duct (CBD) in rats of Groups B and C. In the control Group A, only saline was injected. Re-exploration was done at 3 weeks in Groups A and B and at 6 weeks in Group C, and freshly prepared ICG was injected into the inferior vena cava. Blood samples were collected at periodic intervals, optical density of the serum was measured, and half-life of ICG and fractional clearance (K) were calculated. Blood and tissue samples were obtained for biochemical tests and histological examination. Results: The histological changes in CBD and liver were maximum in Group B; this correlated well with the K-value in this group, which was significantly delayed. In Group C, clearance was delayed than the control group with histological changes ranged from mild to moderate inflammation. The control group had normal histology of liver and CBD, and only four rats showed mild portal inflammation. Conclusion: ICG clearance rate is a reliable marker of liver function and can be utilized for evaluation of liver function in postoperative extrahepatic biliary atresia patients.
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	Congenital pouch colon associated with anorectal malformation: A rare anomaly of Asian Region – experience of Kurdish centre	p. 10
	Rossella Angotti, Qadir Qadir Mohamed Salih, Francesco Molinaro, Francesco Ferrara, Marina Sica, Edoardo Bindi, Mario Messina DOI:10.4103/ajps.AJPS_84_16   Background: Congenital pouch colon (CPC) is an unusual malformation associated with anorectal malformations (ARMs) that are seen especially in Asia. The aim of this study was to analyse our series of CPC associated with ARM in our centre and report our experience based on the rarity of pathology. Materials and Methods: This is a retrospective study conducted at the Department of Paediatric Surgery in North Iraq. We identified patients from a prospectively kept database, including all patients managed between 1997 and 2014. Results: In total, 17 patients (3 females and 14 males) were included; all had CPC and high ARM; male:female ratio was 5.6:1. Two females had colo-vestibular fistula, 1 had a colo-cloacal fistula, all males had imperforate anus with colovesical fistula. Pre-operative diagnosis of CPC was made in eight patients (47%). Four patients (23.5%) had an incomplete pouch colon (Type III and IV), and 13 (76%) had complete pouch colon (Type I and II). All patients were managed with staged surgery. Mortality rate was 17.6% (3/17). Conclusions: CPC associated with ARM can be defined as 'Asian' complex malformation. Few cases are reported in Literature from Europe and USA. However, it is known that it is ever more frequent the collaboration between Asian and European surgeons (as in our study), so the suspicion should be considered in all patient high ARM who come from Asian region. We reviewed literature and report our experience of 15 years, after a retrospectively analysis, to share it and add our data to their reported.
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	Congenital pouch colon: Our experience with coloplasty	p. 16
	Sudhir Singh, JD Rawat, Piyush Kumar DOI:10.4103/ajps.AJPS_88_16   Background: Congenital pouch colon (CPC) or congenital short colon is an entity found mainly in Indian subcontinent. In CPC, colon is replaced with partially or completely abnormal pouch connected to the genitourinary tract by a fistula (colovesical). Management protocol is different in different institute. In this article, we are sharing our three stage standard management approach; principle and technique of coloplasty in cases in which colon length is not adequate for pull through and their follow-up. This study aims to show the result of coloplasty in complete CPC. Materials and Methods: This is retrospective observational study, of 5 years duration. The medical record of these patients was reviewed for demographic information, clinical features, investigations performed, operative notes, post-operative events and the outcome of surgery. Results: Total of 626 ARM cases were managed in 5 years duration in which 64 were of pouch colon. The age of presentation was 1–15 days. In fifty patients who completed their, all stage in that 34 patients were in which coloplasty were done in rest of 16 cases excision of CPC and colonic pull through done in view of adequate colonic length (type III and IV) for pull through. In 34 patient in which coloplasty were done showed satisfactory cosmetic and functional out came after stoma closer in follow-up. Conclusions: Properly created coloplasty and three stage procedure for complete pouch colon give better result and less complications. Excision of pouch is not requiring in all cases of CPC.
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	Nephrectomy in children with wilms' tumor: 15 years of experience with "Tumor Delivery Technique"	p. 22
	Yoram Mor, Dorit Esther Zilberman, Roy Morag, Jacob Ramon, Chaim Churi, Itamar Avigad DOI:10.4103/ajps.AJPS_113_16   Background: The contemporary surgical approach to Wilms' tumors follows that used in adults with renal cell carcinomas, namely, early occlusion of the renal vessels and then removal of the kidney as an intact mass. For years, the surgical approach at our institution has been different, starting with blunt separation of the kidney from the surrounding tissues, followed by its delivery outside the abdominal cavity while it is only attached to the major blood vessels which are subsequently ligated. We aimed to present this "tumor delivery technique" and evaluate its outcomes. Materials and Methods: We retrospectively reviewed medical records of children who underwent nephrectomy for Wilms' tumor using "tumor delivery technique." All procedures were performed by the same team, according to the same surgical principles. Results: Between 2000 and 2015, 36 children were operated. Median age was 31 months (interquartile range [IQR]: 6–45 mo), and median maximal tumor diameter was 10 cm (IQR: 8–13.9 cm). Tumors were located to the right side in 47%, left side in 42%, and bilateral in 11%. Twelve children have received preoperative neoadjuvant chemotherapy. Capsular disruption and tumor spillage were documented in 4 cases (11%). Conclusions: "Tumor delivery technique" is an easy and safe approach which might reduce the overall complication rates and the incidence of intraoperative tumor spillage.
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	Infantile hypertrophic pyloric stenosis – Our experience and challenges in a developing country	p. 26
	Uchechukwu Obiora Ezomike, Sebastian Okwuchukwu Ekenze, Christopher Chim Amah, Elochukwu Perpetua Nwankwo, Nene Elsie Obianyo DOI:10.4103/ajps.AJPS_51_16   Background: This study aims to evaluate the experience and challenges in managing patients with infantile hypertrophic pyloric stenosis (IHPS). Patients and Methods: From January 2007 to December 2015, data from patients with IHPS were retrospectively acquired and analyzed using SPSS version 15. Pearson correlation used to assess linear relationships and Student t-test to compare means. P < 0.05 was taken as statistically significant. Results were expressed as percentages, means ± standard deviation and illustrated in tables and graphs. Results: Twenty-six cases were managed with the mean age at diagnosis of 49.16 ± 21.4 days. Mean birth weight was 3.7 kg and mean weight at presentation was 3.3 kg. Firstborn was affected in 29%; 91% were term deliveries; 9% were post-term; none was preterm; and 36% were exclusively breastfed. Mean duration of symptoms was 25.6 ± 18.9 days. Hyponatraemia was seen in 36%, hypokalaemia 37.5%, alkalosis 35% and hypochloraemia 62%. Mean pyloric tumour length was 22.85 ± 6.56 mm and pyloric wall thickness 5.51 ± 1.36 mm. There was a significant correlation between duration of symptoms and serum potassium level (R = −0.6326, P = 0.002). Mean symptom duration in patients with hypokalaemia was 39.88 ± 23.41 days and without hypokalaemia 17.15 ± 9.78 days (P = 0.006). Mean hospital stay was 9.45 ± 3.27 days. Four patients developed four complications and three patients died (11.5%). Mean age at presentation for pre-operative mortalities was 84 ± 39 days and 46 ± 17.98 days for others (P = 0.015). Conclusions: IHPS presents late in our environment and occurs mainly in term males. There is a significant positive relationship between duration of symptoms and serum potassium level and the mean duration of symptoms was significantly longer in those with hypokalaemia. Pre-operative mortality was significantly associated with longer duration of symptoms.
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	Role of ano rectal myomectomy in children with chronic refractory constipation	p. 31
	Rajeev Gurunath Redkar, Vinod Raj, Anant Bangar, Varun Hathiramani, Swathi Chigicherla, Shruti Tewari DOI:10.4103/ajps.AJPS_99_17   Background: Chronic refractory constipation (CRC) is an uncommon type of constipation. These children have persistent symptoms even after treatment with high dose laxatives, which may cause abdominal distension, vomiting, cramping and bloating. We conducted this study to assess the diagnostic and therapeutic role of anorectal myomectomy in children with CRC. Materials and Methods: This study includes 107 patients who fit the criteria of CRC. Complete bowel preparation with polyethylene glycol solution, enemas and antibiotics was carried out before surgery in all patients. The anorectal myomectomy was carried out under general anaesthesia with the patient in the high lithotomy position. The patients were followed up from 6 months to 13 years postoperatively. The success of myomectomy was based on the daily and complete passage of stools without the need for medication or enemas. Results: A total of 99 patients were included in the study, of which, 86 (86.86%) patients showed a good response to anorectal myomectomy. Of these, 32 patients had normal histology, 14 had histology suggestive of Hirschsprung's disease, 8 had hypoganglionosis, 10 had ultra-short segment Hirschsprung's disease and 22 had hypertrophic nerves with immature ganglia. Poor response was seen in 13 (13.13%) patients of whom 5 had normal histology, 5 had Hirschsprung's disease, 2 had hypoganglionosis and 1 had ultra-short segment Hirschsprung's disease. Conclusion: Anorectal myomectomy is an effective and technically simple procedure in selected patients with CRC for both diagnostic and therapeutic purposes.
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	Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty	p. 36
	Naoki Hashizume, Kimio Asagiri, Suguru Fukahori, Shinji Ishii, Nobuyuki Saikusa, Naruki Higashidate, Motomu Yoshida, Daisuke Masui, Saki Sakamoto, Shiori Tsuruhisa, Yoshiaki Tanaka, Minoru Yagi DOI:10.4103/ajps.AJPS_91_17   Background: Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution. Patients and Methods: Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification. Results: Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation. Conclusions: ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.
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	A 1-year randomized controlled trial to compare the outcome of primary repair of hypospadias with vascular cover using tunica vaginalis flap with those using preputial dartos fascia	p. 42
	Santosh B Kurbet, Ramesh S Koujalagi, V Geethika, Vikram Nagathan DOI:10.4103/ajps.AJPS_104_17   Background: Tubularized incised plate (TIP) urethroplasty is the most common technique noted to correct hypospadias. However, urethrocutaneous fistula (UCF) is still one of the most common complications of this technique. Several techniques of providing vascularized flaps to the neourethra have been recommended to decrease this complication rate. The aim of the study was to assess the outcome of primary repair of hypospadias using tunica vaginalis (TV) flap with those using preputial dartos (PD) fascia. Patients and Methods: Children diagnosed with hypospadias between the age group of 9 months to 18 years, who fulfilled the criteria were randomly divided into two groups by computerized randomization technique. Initially, TIP urethroplasty was done. Children with PD vascular cover were included in Group A and those with TV vascular cover were included in Group B. All the patients were followed up for a minimum of 6 months after surgery. Results: Two (10%) patients in Group A developed UCF and one (5%) patient developed stricture urethra in the follow-up period. None of the patients developed UCF in the Group B. One (5%) patient had stricture urethra in Group B. Two (10%) patient developed meatal stenosis in Group A. Two (10%) patient in Group B developed meatal stenosis. Conclusions:TV flap could be an alternative to PD flap as a vascular cover of neourethra in patients undergoing primary hypospadias repair by TIP urethroplasty.
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CASE REPORTS
	A staged operation for anopenile urethral fistula	p. 48
	Issei Kawakita, Shohei Honda, Hisayuki Miyagi, Masashi Minato, Kazuyoshi Okumura, Akinobu Taketomi DOI:10.4103/ajps.AJPS_52_17   Anopenile urethral fistula (APUF) is not rare, but there are only a few detailed reports regarding its surgical treatment. We describe a patient with APUF who had no anal opening, and meconium was discharged from the external urethral orifice. The patient was treated with a staged operation.
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	Metanephric stromal tumor: An unusual presentation of a rare paediatric renal neoplasm	p. 50
	Nouha Ben Abdeljelil, Rim Hadhri, Manel Njima, Yosra Sghaier, Lassaad Sahnoun, Abdelfatah Zakhama DOI:10.4103/ajps.AJPS_56_17   A 2-year-old boy with prenatal diagnosis of a malformation uropathy was referred to paediatric surgery department. On systemic examination, there were no palpable masses. An ultrasonography of abdomen with color Doppler, a renal artery angiographic and scintigraphy revealed a preostial aneurysm at the left renal artery. The patient had a left nephrectomy. Grossly, the specimen measured 75 mm × mm 50 × 20 mm with renal artery aneurysm measuring 30 mm × 35 mm. On cut section, the renal parenchyma contained a whitish tumor that measured 35 mm × 10 mm. Histopathologically, this tumor was diagnosed as metanephric stromal tumor.
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	Spontaneous common hepatic duct perforation in a child: A rare case report	p. 53
	Kanoujia Sunil, Archika Gupta, Ajay Kumar Verma, Abhishek Kumar Singh, Shiv Narain Kureel, Anand Pandey DOI:10.4103/ajps.AJPS_74_17   Spontaneous perforation of common bile duct is a rare phenomenon; few cases are reported in literature. Hence, there is a dilemma for the management of these cases, but with modern radiological equipment and high degree of suspicion, it is possible to diagnose early. The overall prognosis of this condition is good, provided an early surgical intervention is instituted; we are reporting a case of a 6-year-old male with spontaneous perforation of common hepatic duct. Managed by repair of rent over T-tube, postoperative period was uneventful, T-tube was removed after 3 weeks, and the patient is doing well in follow-up.
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LETTERS TO THE EDITOR
	Meckel's diverticulum: Is this the time for a large multicentric study?	p. 56
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_12_17
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	The evolving surgical approaches in challenged resource settings	p. 58
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_13_17
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	Plastibell circumcision	p. 60
	Sora Yasri, Viroj Wiwanitkit DOI:10.4103/ajps.AJPS_16_18
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	Extrahepatic biliary atresia, liver function tests, and hemoglobin variants	p. 61
	Ioannis Kyriakidis, Athanasios Tragiannidis, Nikolaos Gompakis DOI:10.4103/ajps.AJPS_124_16
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Iatrogenic alkalosis during high-dose methotrexate therapy

INSTRUCTIONS TO AUTHORS AND OTHER LITERARY WORKS OF FICTION
	.	p. 315
	DOI:10.4103/0019-509X.253303
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EDITORIAL
	Risk of second malignancy after modern conformal and proton beam radiotherapy-Minimizing risks, improving survivorshipInstructions to authors and other literary works of fiction	p. 316
	Srinivas Chilukuri, Rakesh Jalali DOI:10.4103/ijc.IJC_549_18
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GYNEC CANCER
	Barriers affecting uptake of cervical cancer screening in low and middle income countries: A systematic review	p. 318
	Pradeep Devarapalli, Satyanarayana Labani, Narayanasetti Nagarjuna, Poonam Panchal, Smita Asthana DOI:10.4103/ijc.IJC_253_18   BACKGROUND: Cervical cancer is the second-most common cancer among women in the developing world and approximately 500,000 cases are diagnosed each year. In developed countries, cervical cancer (CCa) accounts for only 3.6% of newly diagnosed cancers. OBJECTIVE: The present study aims to identify the most effective barriers associated with CCa screening uptake in low and middle-income countries (L and MICs) and aid to adopt effective measures to overcome prevailing barriers to the attainment of CCa uptake in the community. MATERIALS AND METHODS: Health sciences electronic databases like MEDLINE, PubMed, Cochrane library, and Google Scholar were searched for studies published until August 2017. Keywords used for the search were ("cervical cancer screening"), ("barriers"), AND ("low income countries" OR "Middle income countries"). Articles were reviewed and data were extracted by using Mendeley Desktop Software (V-1.17.10). Income-level classification of countries was done as per the World Bank 2017 report. Statistical software like SPSS-V.23 and Medical-V.14 were used for the statistical application. RESULTS: A total of 31 studies met the inclusion criteria with a total of 25,650 participants. The sample size of the included studies ranged from 97 to 5929 participants. Articles majorly reported data on participants from African region (51.6%) and minimally in the Western Pacific region (3.2%). Sampling methods among studies varied from convenience sampling-12 (39.7%) to consecutive sampling-1 (3.2%). Besides, two studies (6.5%) did not discuss their sampling procedures. It was observed that "Lack of information about CCa and its treatment" (Barrier of lack of knowledge and Awareness); "Embracement or shy" (Psychological Barrier); "Lack of time" (structural Barrier); and "Lack of family support" (Sociocultural and religious barrier) were the most commonly reported among all 22 barriers. CONCLUSION: There is a need of policies advancement of CCa screening programs by focusing on aspects of accessibility, affordability, CCa education, and the necessity of screening to improve screening uptake to control the CCa morbidity and mortality rate in L and MIC's.
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	A comparative analysis of quality of life after postoperative intensity-modulated radiotherapy or three-dimensional conformal radiotherapy for cervical cancer	p. 327
	Sarthak Kumar Mohanty, Supriya Chopra, Anisha Mudaliar, Sadhana Kannan, Umesh Mahantshetty, Reena Engineer, Jaya Ghosh, Jyoti Bajpai, Sudeep Gupta, Shyamkishore Shrivastava DOI:10.4103/ijc.IJC_453_17   AIMS: The aim of this study is to compare the quality of life (QOL) between adjuvant three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) for cervical cancer. MATERIALS AND METHODS: QOL assessment was done at the baseline and then longitudinally after completing (chemo) radiation. All patients completed EORTC QLQ-C30 and EORTC QLQ Cx-24 modules. Independent-sample t-test was used to compare the mean scores between the two groups. Analysis of variance was used to compare differences in QOL measures over the six time points (baseline, post-RT, 3, 6, 9, and 12 months after treatment) and between treatment groups (3DCRT vs. IMRT). Linear mixed model was also performed to account for attrition. RESULTS: Overall, 64 patients (image-guided IMRT, n = 40 and 3DCRT, n = 24) completed QOL assessment. The median age and follow-up period were 48 years and 15.5 months, respectively. General QOL domains such as emotional (at 12 months, P = 0.04) and social (at 3 months, P = 0.02 and 12 months, P = 0.03) were better with IMRT. Pain (12 months, P = 0.03); fatigue (12 months, P = 0.05); nausea and vomiting (12 months, P = 0.03); insomnia (post-RT, P = 0.05 and 12 months, P = 0.03); appetite loss (post-RT and 12 months, P = 0.04); and diarrhea (6 months, P = 0.02 and 12 months, P = 0.003) scores were significantly better with IMRT. On linear mixed model analysis, there was a significant interaction between treatment cohort and assessment intervals for physical, emotional, and social functioning, appetite loss, diarrhea, lymphedema, and menopausal symptom scores were significantly better with IMRT. CONCLUSIONS: Treatment technique (IMRT vs. 3DCRT) impacts early QOL in undergoing adjuvant radiation for cervical cancer.
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	Prevalence and nonsexual transmission of human papilloma virus (HPV) in the adolescence girls from rural area of Maharashtra state, India	p. 336
	Atul Budukh, Amita Maheshwari, Vrushali Palayekar, Sonali Bagal, Pallavi Purwar, Kedar Deodhar, Rajesh Dikshit, Rajendra Badwe DOI:10.4103/ijc.IJC_188_18   OBJECTIVE: To find out the prevalence of human papilloma virus (HPV) in adolescent girls and to access the nonsexual transmission of HPV from their mother by using the same old cloth used by their mother. METHOD: Menstrual pads were collected from the women of age group years to find out the presence of HPV and whether it can be used as a cervical cancer screening tool. The results of the said study have been published in the European Journal of Cancer Prevention. During this study, menstrual pads of the daughters of participating women were collected to see the nonsexual transmission of HPV. After conducting the health education and obtaining the informed consent, we interviewed 57 mothers (age group 30–50, married, sexually active) and daughters [age group 12–18, unmarried (not exposed to sex)] from the rural area of Pune district of Maharashtra state, India. The menstrual pads were collected and transported to Mumbai for polymerase chain reaction (PCR) testing. HPV testing was carried out by PCR. RESULTS: Out of 57, 28 (49%) daughters and 23 (40.4%) mothers provided menstrual pad. Out of 23 mothers, one was HPV positive [4.3%: 95% confidence interval (CI) 0.2–23.0] and out of 28 girls, 3 (10.7%: 95% CI 2.0–33.0) were HPV positive. The daughter, whose mother was HPV positive, had negative result for HPV. CONCLUSION: The HPV prevalence in adolescence girls was 10.7%. There may be other nonsexual medium that might have caused HPV in adolescence girls, which needs further research.
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LUNG CANCER
	Correlation between human leukocyte antigen-G expression and clinical parameters in oral squamous cell carcinoma	p. 340
	Xianjun Shen, Peng Wang, Panpan Dai, Bei Jin, Yongqing Tong, Haisheng Lin, Gengsheng Shi DOI:10.4103/ijc.IJC_602_17   BACKGROUND: Human leukocyte antigen-G (HLA-G) is a tumor-associated molecule, whose expression may help the cancer cells to escape the immune response. AIMS: The aim of this study was to evaluate the diagnostic value of HLA-G level in oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS: A total of 52 patients who had definite pathological diagnosis and 20 cases of healthy controls were enrolled in this clinical trial. Immunohistochemisty (IHC) and quantitative real-time reverse transcription-polymerase chain reaction (RT-PCR) analysis were considered for HLA-G identification and multilevel validations. Statistical analysis was performed using SPSS and statistical significance was determined at P < 0.05. RESULTS: IHC results demonstrated that the expression of HLA-G in OSCC was strongly positive and the rate of positive expression was 55.77% (29/52), but the expression of HLA-G in healthy controls was negative (0/20). Furthermore, RT-PCR results showed that the positive expression rate of HLA-G messenger RNA was weak in healthy controls, but strong in OSCC. Besides, HLA-G expression in the tumors was significantly correlated with histological grade. CONCLUSIONS: Our results suggested that HLA-G is associated with the prognosis of OSCC and may serve as a novel therapeutic target.
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BREAST CANCER
	Clinico-pathological characteristics and treatment outcome in invasive lobular carcinoma of the breast: An Indian experience	p. 344
	Ajay Gogia, Vinod Raina, Surya Vansham Suryanarayan Deo, Nootan Kumar Shukla, Sandeep Mathur, Bidhu Kalyan Mohanti, Daya Nand Sharma DOI:10.4103/ijc.IJC_428_18   BACKGROUND: Invasive lobular carcinoma (ILC) is the second most common histologic subtype of breast cancer and accounts for 10%–15% of all breast cancers in the west. There is a scarcity of data on ILC from the Indian subcontinent. This report intends to present the patterns of care, survival outcomes, and prognostic factors of ILC treated in a tertiary care institute. MATERIALS AND METHODS: This retrospective analysis included consecutive patients diagnosed with ILC and registered at our Institute between 2009 and 2016. RESULTS: We included 97 patients with a median age of 53 years (range 28–80). American Joint Committee on Cancer (7th edition) stage distribution was stage I-8.24%, stage II-45.36%, stage III- 34.10%, and stage IV-12.30%. Bilateral breast cancer was seen in 8 cases. Estrogen receptor, progesterone receptor, and HER 2/neu positivity was 90%, 85%, and 9%, respectively. Triple-negative breast cancer constituted 5% of cases. Twenty-nine events were recorded (systemic and locoregional relapse) with a median follow-up of 3.5 years. Three years relapse-free survival (RFS) and overall survival were 80% and 60%, respectively. Bones were the most common site of metastasis. Age <45 years [HR-1.4 (0.8–2.1), P < 0.001] and advanced clinical tumor stage [T4, HR-2.1 (1.1–3.8), P = 0.001] were associated with poor RFS. CONCLUSION: ILC constituted 2.5% of breast cancer cases at our institute. Triple negativity and HER-2/neu positivity were seen in 9% and 5% of cases, respectively. Age <45 years and advanced clinical tumor stage were associated with poor RFS.
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	Comparison of harmonic scalpel and conventional technique in the surgery for breast cancer: A systematic review and meta-analysis	p. 348
	Zili Zhang, Lin Li, Yi Pang, Qi Li, Chunli Guo, Yongchao Wang, Chengpei Zhu, Xiangchao Meng DOI:10.4103/ijc.IJC_306_18   BACKGROUND: Harmonic scalpel is considered as a promising surgical tool for breast cancer, while its advantage over conventional approach is still controversial. Therefore, we performed this meta-analysis to compare the outcomes of harmonic scalpel and conventional tools in the surgery for breast cancer. MATERIALS AND METHODS: Studies reporting the outcomes of harmonic scalpel and conventional technologies were systematically searched from online databases, PubMed and EMBASE up to April 30, 2018. Data were presented as odds ratio, risk ratio (RR), and mean difference (MD) with 95% confidence interval (CI). RESULTS: Intraoperative blood loss (I2 = 96%, P < 0.05, MD = −68.78, 95% CI −93.31 to −44.24), seroma (I2 = 3%, P = 0.41, RR = 0.63, 95% CI 0.46–0.86) and hematoma formation (I2 = 0%, P = 0.64, RR = 0.41, 95% CI 0.23–0.73), drainage volume (I2 = 89%, P < 0.05, MD = −105.33, 95% CI −161.33 to −49.33) and time (I2 = 93%, P < 0.05, MD = −2.18, 95% CI −3.75 to −0.61), necrosis (I2 = 35%, P = 0.20, RR = 0.37, 95% CI 0.16–0.86), surgical duration (I2 = 79%, P < 0.05, MD = −8.49, 95% CI −16.56 to −0.43), and hospital stay (I2 = 97%, P < 0.05, MD = −0.94, 95% CI −1.74 to −0.14) are significantly different between the two groups. CONCLUSIONS: Harmonic scalpel is superior to conventional tools in terms of decreasing intraoperative blood loss, seroma and hematoma formation, drainage volume and time, necrosis prevalence, surgical duration, and hospital stay, which should be strongly recommended in the surgery for breast cancer.
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	Harmonic scalpel versus conventional diathermy: Is one really better than the other?	p. 359
	Suhani DOI:10.4103/ijc.IJC_551_18
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	Comparison of resection margins and cosmetic outcome following intraoperative ultrasound-guided excision versus conventional palpation-guided breast conservation surgery in breast cancer: A randomized controlled trial	p. 361
	Tejas Vispute, Suhani, V Seenu, Rajinder Parshad, Smriti Hari, Sanjay Thulkar, Sandeep Mathur DOI:10.4103/ijc.IJC_2_18   INTRODUCTION: Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS. MATERIALS AND METHODS: This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently. RESULTS: Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity. CONCLUSIONS: Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method.
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	Examination of methylation changes of VIM, CXCR4, DOK7, and SPDEF genes in peripheral blood DNA in breast cancer patients	p. 366
	Atefeh Shirkavand, Zahra Niki Boroujeni, Seyed Ahmad Aleyasin DOI:10.4103/ijc.IJC_100_18   BACKGROUND: Studying whole blood DNA methylation as a risk marker has valuable applications in either diagnosis or staging of breast cancer. We investigated whole blood DNA methylation status of VIM, CXCR4, DOK7, and SPDEF genes in breast cancer patients in comparison to healthy control subjects. MATERIALS AND METHODS: 60 patients with breast cancer and 40 healthy controls were examined. Genomic DNA isolated from peripheral blood and restriction enzyme polymerase chain reaction (REP) method was applied for analysis. Real-time PCR was used to confirm methylation status of the aforementioned genes and therefore to find out the methylation differences between normal and breast cancer subjects. RESULTS: Level of DOK7 promoter hypomethylation in normal and breast cancer samples was significant (P-value = 0.001). The study, also, showed that hypomethylation of VIM and CXCR4 genes are significant in patients compared with normal cases (P-value < 0.05). Furthermore, SPDEF promoter hypomethylation was not significantly differed between normal and breast cancer samples (P-value = 0.2). CONCLUSIONS: Hypermethylation of DOK7 gene in DNA from patients affected with breast cancer offers a biomarker for diagnosis of the breast cancer. This study indicates that methylation status of VIM and CXCR4 genes changes in breast cancer; so, they can be used as molecular biomarkers in breast cancer prognosis.
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BRAIN TUMORS
	The risk of secondary cancer in pediatric medulloblastoma patients due to three-dimensional conformal radiotherapy and intensity-modulated radiotherapy	p. 372
	Reham S Sherif, Wael M Elshemey, Ehab M Attalla DOI:10.4103/ijc.IJC_410_18   BACKGROUND: Craniospinal irradiation (CSI) is the standard radiation therapy treatment for medulloblastoma. The aim of this study was to estimate and compare the lifetime risk of radiation-induced secondary cancer in pediatric medulloblastoma patients using three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: 3D-CRT and IMRT plans were performed for 10 CSI pediatric patients. The average absorbed doses for organs at risk (OARs) was calculated from dose-volume histograms on the treatment planning system. The average lifetime risk of radiation-induced secondary cancer was then calculated. RESULTS: Lifetime risk of secondary cancer for CSI pediatric patients treated using IMRT decreases in some OARs compared with those treated using 3D-CRT. This is attributable to the decrease in the average absorbed dose in some OARs when using IMRT technique. CONCLUSION: Follow-up of medulloblastoma pediatric patients should be performed after ending the treatment course in order to diagnose early secondary tumors. IMRT technique is substantially better than 3D-CRT in terms of lifetime risk of radiation-induced secondary cancer, probably due to reduced dose to OARs especially to the thyroid, which is the most sensitive organ to radiation.
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SHARED DECISION MAKING
	Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making: An exploratory study	p. 377
	Rana F Obeidat, Robin M Lally DOI:10.4103/ijc.IJC_122_18   BACKGROUND: Successful implementation of shared decision-making in clinical encounters is influenced by system, patient, and clinician factors that both facilitate and present barriers to patient-centered care. Little is known about which factors Jordanian physicians believe influence their ability to implement shared decision-making with cancer patients. AIMS: To determine Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making. SETTINGS AND DESIGN: A cross-sectional exploratory survey design was used in the study. A convenience sample of 86 Jordanian medical and radiation oncologists and surgeons was recruited. MATERIALS AND METHODS: A valid measure of physicians' views of shared decision-making was slightly modified from its original English and used to collect data. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for windows version 19.0 (SPSS, Inc., Chicago, IL, USA). Descriptive and inferential statistics were carried as appropriate. RESULTS: Insufficient time to spend with the patient, patient expecting a certain treatment rather than a consultation, and the patient's family overriding the decision-making process were the most frequently reported barriers to patient participation in treatment decision-making. Physicians believed that patients trust in physicians and patient being accompanied at the consultation were important facilitators of patient participation in treatment decision-making. CONCLUSIONS: Jordanian physicians perceive multiple barriers to patient participation in treatment decision-making. Patient-related difficulties (e.g., indecision), and system-related difficulties, in particular, patient's family influence on the decision-making process are more prevalent among Jordanian physicians compared to Western physicians.
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TOBACCO
	Effectiveness of two psychological intervention techniques for de-addiction among patients with addiction to tobacco and alcohol – A double-blind randomized control trial	p. 382
	Rahul Ganavadiya, B R Chandra Shekar, S Suma, Pallavi Singh, Ruchika Gupta, Poonam Tomar Rana, Shubham Jain DOI:10.4103/ijc.IJC_650_17   Objective: The objective of this study was to evaluate effectiveness of two psychological intervention techniques (reading – writing therapy vs. games – narrative therapy) using motivational intervention alone as a control among tobacco addicts. Materials and Method:This randomized control trial was conducted over a period of 6 months from April to September 2013 at a de-addiction center in Madhya Pradesh, India. Patients with moderate-to-high levels of dependence as determined by Fagerstrom Test for Nicotine Dependence (FTND) admitted for treatment in a de-addiction center were recruited. A cluster randomization technique was used for allocation of participants to three different groups. Group allocation was concealed from investigator and done by coordinator. Three interventions were group A – motivational intervention alone, group B – games and story therapy along with motivational intervention, and group C – reading and writing therapy along with motivational intervention. Interventions were applied for 1 month. Two postintervention follow-ups (one at the time of discharge and one after 1 month following discharge) were done to assess level of dependence using FTND besides undertaking urine cotinine analysis among three randomly selected participants in each group. Results: A total of 82 participants (28 in group A, 27 each in groups B and C) completed the study. Eighty-one (98.8%) participants had complete abstinence at the end of 1 month with no significant difference in the success rate between different categories (P = 0.357). At the end of 1 month following discharge from center, only 7 participants (8.5%) had complete abstinence and 51 participants (62.2%) had partial reduction and remaining 24 participants (29.3%) were considered failures with no difference between three groups (P = 0.768). Conclusion: Although overall abstinence was low (8.5%), all intervention techniques were equally effective in at least reducing level of dependence with no significant difference in their efficacy.
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	Designing and validation of text messages for m-Health intervention for tobacco cessation and management	p. 390
	Puneet Chahar, Vikrant R Mohanty, YB Aswini DOI:10.4103/ijc.IJC_569_17   BACKGROUND: Tobacco is a growing epidemic and tobacco-related death results in health consequences and lost economic opportunities. Tobacco cessation efforts mandate the use of multiple strategies to bring about behaviour change. AIM: To develop and validate health promotive text messages using transtheoretical model and prospect theory for behaviour change. SETTINGS AND DESIGN: The present observational study was conducted in a tertiary care hospital, Delhi among patients reporting at Tobacco Cessation Centre (TCC). METHODS: The study was divided into two phases: first involved development of text messages in local language (Hindi) using a sound theoretical basis (TTM and prospect theory) and second phase dealt with validation of the developed text messages by patients and experts in the field of tobacco cessation. STATISTICAL ANALYSIS: Descriptive statistics was obtained using the SPSS version 17. RESULTS: The sample comprised 20 males and 6 females. Average appeal score ranged from 6.1 to 9.6 (54 messages). Forty two messages out of a total of 54 messages were found to be appropriate after validation by the experts. Mean words of the final messages (42 messages) was 24.5 ± 1.3. Two hundred ninety one (90%) out of a total of 324 questionnaires showed adequate understanding of message as assessed by the reviewers. CONCLUSIONS: The current effort developed and validated health promotive text messages package to aid in tobacco cessation. The preventive text messages were grounded in evidence and sound theoretical basis and followed a standard validating procedure leading to satisfactory understanding and appeal in all domains.
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	The tobacco trade and trail in Karnataka	p. 394
	Punith Shetty, Roomani Srivastav, Arpan Debnath, R Murali, A Shamala DOI:10.4103/ijc.IJC_131_18   CONTEXT: Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Despite innumerable laws, the overall picture of the current system is not clear and the menace of tobacco persists. What does it take to stop this menace? The present study made an attempt to throw some light on the prevailing discrepancy in the current system. AIMS: The aim of the study was to explore the knowledge and attitude of people involved in growth and sales of tobacco. MATERIALS AND METHODS:This qualitative research was aimed at farmers growing tobacco in Mysore district and vendors selling tobacco in Bangalore. Snowball sampling technique was used to select the farmers. Simple random sampling technique was used to shortlist vendors selling tobacco products in Bangalore. Data were collected using semistructured questionnaire through interviews which were recorded using an audio recorder. RESULTS: Inductive analysis was conducted for the present study and the responses were divided into three categories, that is, awareness of laws, compliance to laws, and opinion regarding banning tobacco. Ninety percent of the growers and all the tobacco vendors (100%) were aware of the laws governing them; however, the compliance was poor in both the populations (32% and 20%, respectively). CONCLUSIONS: Implementation of law is an area that needs to be strengthened. Violations of these laws are not adequately reported; this matter should be dealt with. It was seen that the system which creates the laws itself promotes the growth and thereby the distribution of the tobacco products.
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	Nicotinic acetylcholine receptor gene polymorphism is not associated with tobacco-related oral squamous cell carcinoma	p. 399
	Deepa Rajesh, SM Azeem Mohiyuddin, Sharath Balakrishna, A V Moideen Kutty DOI:10.4103/ijc.IJC_325_18   BACKGROUND: Nicotinic acetylcholine receptor is implicated in carcinogenesis indirectly through increasing nicotine dependence and directly through its impact on cell-cycle regulation. Functional polymorphism in nicotinic acetylcholine receptor alpha-5 subunit gene (CHRNA5 c.1192G>A; rs16969968) is associated with nicotine dependence and risk of lung cancer. AIM: The aim of this study was to evaluate the association of CHRNA5 c.1192G>A polymorphism with the risk of oral squamous cell carcinoma (OSCC). SETTINGS AND DESIGN: This was a rural teaching hospital-based case-control study. MATERIALS AND METHODS: A total of 100 histopathologically confirmed cases of OSCC patients and 100 age- and gender-matched healthy individuals were genotyped for CHRNA5 c.1192G>A polymorphism by polymerase chain reaction-restriction fragment length polymorphism method. Allele and genotype frequencies among case and control groups were compared by Chi-squared test (Fisher's exact). RESULTS: The frequency of CHRNA5 c.1192A allele was 22% in OSCC patients and 26% in control individuals. The difference in the distribution of alleles and genotypes between case and control groups was not significant (P > 0.05). CONCLUSIONS: CHRNA5 c.1192G>A polymorphism is not associated with the risk of developing OSCC.
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	Prevalence of oral mucosal lesions among smokeless tobacco usage: A cross-sectional study	p. 404
	Kaveri Hallikeri, Venktesh Naikmasur, Kruthika Guttal, Mangalore Shodan, Niranjan Kochli Chennappa DOI:10.4103/ijc.IJC_178_18   BACKGROUND: Tobacco use is one of the most prevalent forms of habit and associated with development of potential malignant disorders. The aim of the present study was to investigate the prevalence and distribution of oral mucosal lesions (OMLs) among smokeless tobacco users. MATERIALS AND METHODS: This is a hospital-based cross-sectional study. All the patients with the history of smokeless tobacco habit were included in the study. The patients were interviewed using the preformed questionnaire, including the patient's demographic details, the type of habit, duration, frequency, and the associated oral mucosal pathology. Further, patients were clinically examined and recorded on tobacco-related oral lesions. RESULTS: Prevalence of OML was 54.18%, and 91.50% being among male and with higher frequency at the age of second and fourth decade. The prevalence of oral submucous fibrosis, leukoplakia, carcinoma, lichen planus, and erythroplakia was 26.95, 10.35, 9.94, 5.5, and 0.66%, respectively. Smokeless tobacco habit was prevailing among males (98.79%) compared to females (9.37%). Frequency of habit-associated OML was statistically significant with odds ratio 0.24. CONCLUSION: The study proves a definite association between smokeless tobacco habit and OML. The data necessitate to correlate and follow up the individuals with smokeless form of tobacco habits to establish the definite correlation between the habit and oral mucosal lesions.
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CASE REPORTS
	A novel frameshift mutation in the MLH1 gene in a patient with Lynch syndrome	p. 410
	Arti S Pandey, Sudip Shrestha DOI:10.4103/ijc.IJC_349_18   A novel mutation in the MLH1 gene likely to be pathogenic for Lynch syndrome was discovered in a proband with a family history of colon cancer. Immunohistochemistry showed negative expression of PMS2 and MLH1 in the resected tumor sample. The mutation lies at the highly conserved C-terminus of the MLH1 protein, the region through which it dimerizes with PMS2 to carry out its mismatch repair function.
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	Creatinine kinase elevation and peripheral neuropathy during nivolumab treatment of a patient with metastatic renal cell carcinoma	p. 413
	Melih Simsek, Mehmet Bilici, Salim Basol Tekin DOI:10.4103/ijc.IJC_151_18   We report elevation of creatinine kinase (CK), which is an uncommon adverse event related to treatment with nivolumab. Nivolumab is a monoclonal antibody against programmed cell death-1 and an effective agent in metastatic renal cell carcinoma (RCCa). Here, we report a case of 58 year-old male receiving nivolumab as fourth-line treatment for metastatic RCCa. The patient was admitted to our clinic with pelvic pain and weakness in his legs. Elevated CK level was noted and he was hospitalized. About 1 mg/kg methylprednisolone was initiated and nivolumab was discontinued. On the second day of his hospitalization, left facial palsy occurred. After his neuropathy improved and CK level normalized, the patient was discharged. Neurological immune-related adverse events are very rare with nivolumab but can be serious.
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IMAGES IN ONCOLOGY
	Trousseau's sign in the left internal jugular vein in gastric cancer	p. 415
	Dillibabu Ethiraj, Venkatraman Indiran, Kannan Kanakaraj, Prabakaran Madhuraimuthu DOI:10.4103/ijc.IJC_321_18
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VIEWPOINT
	Potential role of whole-body diffusion magnetic resonance imaging in tumor staging for pregnant patients with cancer	p. 417
	Abhishek Mahajan, GV Santhosh Kumar, Tanvi Vaidya, Meenakshi Thakur, Subhash Desai DOI:10.4103/ijc.IJC_244_18   Malignancy during pregnancy poses a serious threat to the growing fetus. In this special situation, the diagnostic procedures and treatment to cancer will be more damaging to the developing fetus than the cancer itself. However, to safeguard the health of the mother from cancer, appropriate diagnostic and therapeutic tools are to be used that would minimize risk to fetal health. Diffusion-weighted whole-body imaging with background body signal suppression has the potential to answer most of these diagnostic dilemmas in the case of malignancy in pregnancy. This is one of the first such reports highlighting the role of a noninvasive, nonionizing whole-body imaging technique which does not require external contrast injection and can also be used for monitoring treatment response.
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	Cancer has almost a similar psychosocial impact on family caregivers as those of the patients; but are we doing enough for them?	p. 419
	Sourav Goswami, Subodh Saran Gupta DOI:10.4103/ijc.IJC_628_18
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LETTER TO THE EDITOR
	Skin and mucosal ulcerations and acute kidney failure due to methotrexate toxicity in a patient with non-Hodgkin's lymphoma	p. 421
	Xia Song, Yinyin Guo, Hui Zhao, Wenbiao Hu DOI:10.4103/ijc.IJC_195_18
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	Health and well-being of cancer caregivers in a changed role of breadwinners	p. 422
	Md Mahbub Hossain DOI:10.4103/ijc.IJC_266_18
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	Iatrogenic alkalosis during high-dose methotrexate therapy: An avertable cause	p. 423
	Kritika Agrawal, Satyajit Majhi, Nishkarsh Gupta, Rakesh Garg DOI:10.4103/ijc.IJC_92_18
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HISTORY OF CANCER
	A pituitary tumor turned-to-be a glioma: A surgical case from the Madras General Hospital 1928	p. 424
	Ramya Raman, Anantanarayanan Raman DOI:10.4103/ijc.IJC_12_19   A three-page paper entitled "A case of glioma (embryonal neurocytoma) of the brain simulating pituitary tumour," written by K. G. Pandalai, Surgeon at the Madras General Hospital, and T. B. Menon, Pathologist at the Madras Medical College, was published in the Indian Medical Gazette. This paper refers to an occasional finding of a brain tumor (a glioma), presurgically diagnosed as a pituitary tumor, in 1928. This was close to the period when surgeons across the developed world believed in that cancers were by no means common among the native people of India as it was in Europe. Leopold Rogers of the Bengal Medical Service, Calcutta, in 1925 refuted this belief indicating that malignant tumors were equally common in Bengal (India) and England. Nevertheless, this report by Pandalai and Menon strikes a unique chord since the tumor was subsequently determined as a glioma – an embryonal neurocytoma -– with adequate evidences drawn from the state-of-the-art volume "A classification of the tumors of the glioma group on a histogenetic basis with a correlated study of prognosis" by Percival Bailey and Harvey Cushing published in Philadelphia in 1926. This Pandalai-–Menon report impresses as pioneering and trailblazing, on a brain tumor detected in 1928, given that earliest exclusive departments of neurosurgery were established in Christian Medical College, Vellore, and Madras Medical College, Madras, by Jacob Chandy and Balasubramanian Ramamurthi, respectively, nearly two decades later.
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