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   Table of Contents - Current issue
January-June 2019
Volume 2 | Issue 1
Page Nos. 1-86

Online since Monday, June 3, 2019

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World Health Organization 2016 update on classification of central nervous system tumors: The road ahead p. 1
Dattatraya Muzumdar
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Management of optic pathway gliomas: Role of magnetic resonance imaging with diffusion-tensor imaging tractography in planning surgical resection p. 3
Manas Panigrahi, Chirag Patel, Y B. V K. Chandrasekhar, Sudhindra Vooturi
Optic pathway gliomas (OPGs) are histological low grade but widely infiltrative tumors that arise along the optic nerves, optic chiasm, tracts, diencephalic structures, and white matter radiations to the visual cortex. When OPGs progress, management strategies may differ between pre-chiasmatic and chiasmatic lesions. Radiation therapy is often utilized as the primary treatment modality, but it is typically postponed till the age of 5–7 years because of the potential for late risks such as endocrinopathy, vasculopathy, and cognitive decline. No definitive studies establish the superiority of one specific chemotherapeutic agent over others. However, a favorable side effect profile is often opted for. Surgery is considered in patients with (1) single nerve is involved, (2) progressive and disfiguring proptosis, (3) blindness, and (4) significant mass effect or hydrocephalus. Encouragingly, diffusion-tensor imaging (DTI) has emerged as a useful tool for the assessment of white matter structures, including the visual pathways. We report an interim analysis of 14 patients with OPG, at our center, a tertiary referral center. We report that magnetic resonance imaging (MRI)-DTI studies provided additional information about visual fiber arrangement in relationship to the tumor that was not evident by conventional MRI methods.
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Simultaneously occurring tumors with acoustic schwannomas without phakomatoses – A case series of nine patients and review of literature p. 7
Dattatraya P Muzumdar, Sonal Jain, Abhidha Shah, Atul Goel
Introduction: Primary brain tumors of different histological types developing spontaneously together is a rare event; the incidence being 0.3% of all brain tumors. Acoustic schwannomas form the majority (about 70%–80%) of all cerebellopontine angle tumors. The most common association found is meningioma and acoustic schwannoma occurring in the same cerebellopontine angle region. Excluding phakomatoses, other neurocutaneous syndromes, and previous irradiation; the simultaneous occurrence of different primary brain tumors with acoustic schwannoma is rare. Methodology: We report the largest single institute case series, 9 patients of simultaneously occurring primary tumors with acoustic schwannomas over the last 25 years (1990–2015). All these patients were operated for both the tumors. The classification, pathogenesis, and surgical strategy of such tumors are discussed in light of current literature. Results: There were five males and four females in the study population aged from 30-60 years. There were five patients with spatially distant co-existing tumors. Transient facial paresis was noticed in three patients. They had significant improvement within six months. Conclusion: Simultaneously occurring tumors need appropriate planning and surgical strategy for ensuring good outcome and long-term prognosis.
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Early initiation of radiotherapy in patients diagnosed with gliomas: A retrospective analysis of patient in a single institution a tertiary care center p. 12
Anusheel Munshi, Shaleen Agrawal, Sandeep Vaishya, Rana Patir, Rakesh Gupta, Biplab Sarkar, Tharmar Ganesh, Bidhu K Mohanti
Objective: Evaluation of effect of interval between surgery to adjuvant radiotherapy (Sx-ART) start and its early tolerance in glioma patients. Method: A retrospective study of 155 adult glioma patients (WHO Grade II-IV) who underwent adjuvant radiotherapy (ART) post-surgery with confirmed histopathology was done in our institution from Sept, 2012 to May,2017. Results were analysed in 3 parts: Sx-ART interval, ART schedule, ART course tolerance. Results: Sx-ART interval ranged from 1-8wks. Seventy-eight percent (121/155) patients started ART within 4wks of surgery, 30/155(19.4%) started within 2wks and 89/155 (57.4%) within 3wks of surgery. ART schedule was conventional fractionation (CF) in 121 (78%) while 34/155 (22%) patients received hypofractionated (HF) course. CF schedules varied between 54Gy-61Gy in 28-33 fractions and HF ranged 50Gy-55Gy in 20-25 fractions. Duration of ART ranged 24-50 days (median 41days). Sixty-five percent (101/155) patients completed ART <6wks and 147/155 (95%) <7wks. Seventy-eight percent (121/155) patients had concurrent Temozolomide (TMZ) including 28/34 (82%) HF patients. ART course interruption was recorded in 11/155 (7%) patients. Interruptions for Sx-ART interval <3wks & >3wks was 3 & 8 patients respectively. None had Grade 3/4 skin reactions or post-treatment scar infection/gaping at ART conclusion. Conclusion: Early start of ART in this analysis showed no difference in tolerance to radiotherapy, including patients receiving HF radiotherapy or concomitant temozolomide. Decrease in time interval from surgery to start of radiotherapy may improve compliance to radiotherapy and reduce overall duration of treatment time (ODT). Long term data of such approaches to reduce ODT and its effect on disease free and overall survival require future studies.
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Antiepileptic drug usage in neuro-oncology: A practice survey p. 17
Amrita Parhi, Tejpal Gupta
Purpose: Despite the lack of high-quality evidence, anti-epileptic drugs (AEDs) are very commonly prescribed for seizure prophylaxis in patients with brain tumors even without prior history of seizures. We sought to review the current practices of prescribing AEDs among neuro-oncology health-care professionals. Materials and Methods: An e-mail with online link to a 15-item questionnaire regarding AED prophylaxis was sent to members of major academic societies representing the Indian Neuro-Oncology Community to assess the prevalent patterns of practice. Results: The online survey was completed by 318 of 3320 health-care professionals that were mailed for an overall response rate of 9.6%. Majority (68.9%) of respondents were radiation oncologists followed by neurosurgeons (22.9%) and medical oncologists/neurologists (8.2%). The practice setting spanned across the health-care spectrum, and over 75% reported having ≥ 5-year of experience in managing patients with brain tumors. Even for seizure-naïve patients, 65.1% of respondents routinely prescribed prophylactic AEDs with significant variability in the duration of such prophylaxis. Levetiracetam was the most preferred AED (60%) followed by phenytoin (35%) in the survey. Most respondents believed that tumor type, histological grade, and anatomic location influenced the risk of seizures. Despite widespread use in clinical practice, only 27.3% of the respondents strongly believed that prophylactic AEDs significantly reduced the risk of seizures. Over 93% of respondents agreed that a large randomized controlled trial would better inform therapeutic decision-making regarding AED prophylaxis. Conclusions: This survey of the Indian Neuro-Oncology Community demonstrates widespread variability in the frequency and duration of AED prophylaxis in seizure-naive brain tumor patients in contemporary practice.
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Ganglioneuroblastoma of the paracavernous region p. 24
Kanika Bansal, Sandeep Vaishya, Rakesh K Gupta, Sunita Ahlawat, Anusheel Munshi
Brain tumors commonly seen in the third decade of life are germinomas, medulloblastomas, and gliomas. A 21-year-old male presented with an extra-axial mass lesion in the right paracavernous and cerebellopontine region of the brain. Postoperative histopathology was ganglioneuroblastoma (GNB). We present the first report of GNB of this region of the brain along with a literature review of the past cases.
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Neuroendocrine variant of carcinoma of the prostate p. 27
RB Nerli, Shridhar C Ghagane, K Shankar, Rafat Jamadar K, Sushant Deole, Neeraj S Dixit, Murigendra B Hiremath
Alterations in the differentiation pathway of prostate cancer can be seen in a small proportion of patients, giving rise to a neuroendocrine (NE) variant. Such tumors possess a number of biologic characteristics unique to NE tumors that can also arise from other organs. Rapidly growing disease with the following clinical characteristics such as pelvic masses, visceral involvement, osteolytic metastasis with hypercalcemia, and brain metastasis should prompt evaluation for the NE variant. We report a case of NE variant of prostatic carcinoma presenting in an elderly male and rapidly progressing to metastasize even the brain.
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Papers Abstracts p. 30

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Poster Abstracts p. 75

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