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Anil Kumar Dhull1

The word vinegar derives from the Old French vin aigre, meaning sour wine.Vinegar is the result of two biochemical processes: alcoholic fermentation, which converts natural sugars into alcohol, and acid fermentation, in which microorganisms present in the air we breathe, convert the alcohol into acetic acid. Anil Kumar is an Mumbai based astrologer who provide Scientific consultation on Astrology, Numerology, Palmistry, Matchmaking and Vaastu in Mumbai, India.

*, Kamal Nain Rattan2, Vivek Kaushal1, Manas Dubey1 and Veena Gupta3*Correspondence: Anil Kumar Dhull, Department of Radiation Oncology, Regional Cancer Centre, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Haryana, India, Tel: +919812011011, Fax: +91-126-22-9999, Email:

Abstract

We are presenting a 2-year male child with large abdominal mass extending from right inguino-scrotal region to suprapubic region of size 4.0 × 5.0 cm. Mass causing pressure effect over bilateral kidneys and ureters with bilateral dilated renal pelvis and extending into the right inguinal region and pelvis. Histopathologically and immunocytochemically patient was confirmed as rhabdomyosarcoma of the retroperitoneum. Patient treated with six cycles of infusion chemotherapy with 3- weekly VAC regimen and was having progressive disease because of the aggressive behaviour of the disease and further treated with second line chemotherapy. The present case is a very unusual and rare site of metastatic presentation of the Rhabdomyosarcoma.

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Keywords

Metastatic Rhabdomyosarcoma, RMS, Retroperitoneal mass, Giant Paediatric Tumor, VAC chemotherapy.

Introduction

Sarcomas are a heterogeneous group of malignancies of mesenchymal cell origin that develop at primary sites throughout the body. Paediatric soft tissue sarcomas form a heterogeneous group of non-epithelial extra skeletal malignancies, representing 7% of all childhood tumors, approximately half of which are Rhabdomyosarcomas and the rest are Nonrhabdomyosarcomatous soft tissue sarcomas.

Rhabdomyosarcoma (RMS) is the commonest, highly malignant soft tissue sarcoma of childhood and adolescents, which accounts for 3% of all pediatric tumors [1]. Incidence peaks in children aged 1-4 years [2]. Tumors located in the trunk, the upper and lower limbs occur more frequently in adolescents and are generally the alveolar type. Only around 13% of RMS has evi-dence of metastatic disease at the time of the initial presentation [3]. Here, we are presenting a very unusual case of metastatic RMS.

Case Report

A 2-year-old male child presented with history of lump in right inguino-scrotal region and abdominal mass since two months. Scrotal lump gradually increased in size and was associated with abdominal guarding and tenderness. There was no history of associated pain, fever or any significant past or medical history. Systemic examination revealed hard indurated abdominal mass extending from right inguino-scrotal region to suprapubic region of size 4.0 × 5.0 cm.

Complete hemogram and routine blood biochemistry parameters of the patient were within normal limits.

Chest radiograph of the patient was normal. Contrast enhanced computed tomography (CECT) scan of abdomen revealed a heterogeneously enhancing mass lesion measuring 3.7 × 3.0 × 4.7 cm in right side of scrotum. Another large heterogeneously enhancing mass lesion was seen in retro peritoneum extending up to pelvis. The mass was displacing gut loops and showing pressure effect on bilateral kidneys (Figure 1).

Figure 1. (A) Contrast enhanced computed tomography (CECT) scan of abdomen revealing large heterogeneously enhancing mass seen in retroperitoneum causing encasement of the descending aorta. The mass is displacing the bowel loops anteriorly and laterally. Inferior vena cava (IVC) is not visualized and likely in compressed state. (B) Large mass seen to be extending from the vertebral body till pelvis and right inguinal region. (C) Mass causing pressure effect over bilateral kidneys and ureters with bilateral dilated renal pelvis. (D) Mass extending into the right inguinal region and pelvis.

Cytopathology of the retroperitoneal mass was having dilemma between rhabdomyosarcoma and malignant small round cell tumor. Patient underwent retroperitoneal lymph node dissection with orchiectomy of the affected side. The neoplastic cells illustrated wide spread positivity for Myogenin, Desmin and B-cell lymphoma 2 (BCl2) stain and stain for Cytokeratin (CK), Leukocyte Common Antigen (LCA), Smooth Muscle Actin (SMA), S-100, PLAP, CD-30, CD-56, CD-99, CD-117, Vimentin and Synaptophysin were negative (Figure 2). Histopathologically and immunocytochemically patient was confirmed as rhabdomyosarcoma of the retroperitoneum. With this diagnosis, patient was treated with six cycles of infusion chemotherapy with 3-weekly VAC regimen (vincristine, doxorubicin and cyclophosphamide). After completion of 6-cycles of VAC chemotherapy, patient was presenting with progressive disease and further decided to give six more cycles of three weekly, second line infusion chemotherapy with carboplatin plus etoposide (carboplatin day 1 and etoposide day 1 to 3). Presently, patient is having non-progressive disease and on regular follow-up.

Figure 2. A-H (A) Microphotograph revealing nuclear positivity for myogenin in tumor cells. (IHC; 200x); (B) Microphotograph showing pleomorphic tumor cells arranged in sheets. The cells have moderate amount of eosinophilic cytoplasm, vesicular nuclei with prominent nucleoli. (H&E; 100x); (C) Microphotograph showing tumor cells arranged in sheets. The cells have moderate amount of eosinophilic cytoplasm, nuclear pleomorphism, and vesicular nuclei with prominent nucleoli. Mitotic figures are also evident. (H&E; 200x); (D) Microphotograph showing tumor cells arranged in sheets. The cells have moderate amount of eosinophilic cytoplasm, nuclear pleomorphism, and vesicular nuclei with prominent nucleoli. Mitotic figures are also evident. (H&E; 400x); (E) Microphotograph showing tumor cells arranged in alveolar pattern. (H&E; 40x); (F) Microphotograph showing tumor cells arranged in alveolar pattern. (H&E; 100x); (G: Microphotograph showing tumor cells arranged in alveolar pattern. (H&E; 200x); (H): Microphotograph showing tumor cells arranged in alveolar pattern. (H&E; 400x).

Discussion

Rhabdomyosarcoma (RMS) is the commonest, highly malignant soft tissue sarcoma of childhood and adolescents, which accounts for 3% of all pediatric tumors [4]. Incidence peaks in children aged 1–4 years, lower in children aged 10–14 years and lowest between 15-19 years [5]. RMS is derived from immature striated skeletal muscle; hence, this disease can virtually occur anywhere in the body, though there are distinct clinical patterns according to the age at presentation, the histologic subtype and the site of the tumor. Head and neck tumors, including those in parameningeal locations tend to occur in children less than 8-years of age and are usually the embryonal type. Tumors located in the trunk, the arms, or the legs occur more commonly in adolescents and are usually the alveolar type. Bladder and vaginal tumors tend to occur in infants and in very young children and are the botryoid type of embryonal rhabdomyosarcoma. Only about 13% of patients with RMS have evidence of metastatic disease at the time of the diagnosis. The lung parenchyma is the most common site of metastasis, followed by bone marrow, bone and locoregional lymph nodes [6]. The present case is a very unusual and rare site of metastatic presentation of the RMS.

Patients with primary metastatic or recurrent RMS have a very poor prognosis, but the prognosis of patients with localized RMS has improved significantly with multidisciplinary management in the last two decades with an event-free survival (EFS) rate of approximately 70% [2]. Primary disseminated tumors in the Intergroup Rhabdomyo-sarcoma Studies IRS I, II and III have shown 5-year survival rates of patients between 20-30% [1,7-9].

Current therapy of RMS involves use of several treatment modalities like surgery, radiotherapy and chemotherapy. The cure rate with localized RMS has markedly improved three times over the past 2-decades, but children’s with metastatic disease at presentation have not much benefited and urgently need innovative therapies. Patients with metastatic RMS, with age more than 10-years and with embryonal RMS, have estimated long-term EFS of less than 20% [1,7-9].

Staging procedures include computed tomography (CT) or magnetic resonant imaging (MRI) studies of the primary site, CT scan of the chest, bone scan, bone marrow aspirates/biopsies, and lumbar puncture for the parameningeal localized sites. Several imperative prognosticators have been found in recent treatment strategies and patients are categorized accordingly to guide risk adapted therapy. Risk factors include the site of the primary tumor; the magnitude of the initial surgical resection; the age at diagnosis, with infants and adolescents generally faring less well than children 2-10 years old; the histologic type; the tumor–node– metastasis (TNM) stage and response to therapy.

The treatment approaches includes surgical resection, chemotherapy, radiation therapy individually or in combination. Chemotherapy remains the mainstay of treatment to reduce the size of the primary tumor and to eradicate gross or micro-metastases. Complete resection cannot be achievable in most of the patients because of the location of majority of RMS's. Radiotherapy is mostly used to control residual bulky or microscopic disease, particularly when the tumor is located in nonfeasible sites for surgery [2].

In the last three decades, there is a revolution in the treatment strategies for RMS of the head and neck region. Long-term comparative studies and metaanalysis helped the international medical fraternity to create new treatment modalities that are composed of combination chemotherapy, radiation therapy and surgery and this has significantly improved the prognosis in majority of the patients. According to American and European statistics data, the overall 5- year survival rate is now 73% and 71% re-spectively [9]. Unfortunately, outcome of the patients with metastases at the time of di-agnosis are still suspicious and these accounts for 15% of all pediatric patients with RMS and their prognosis has not much improved in last 15-years with a 5-year survival rate of only 20–30% [2,7-9]. The disease is challenging with recurrent tumor though temporal complete remission after second line treatment is possible but with poor probabili-ties for complete recovery [10].

The most effective chemotherapy agents against rhabdomyosarcoma cells are vincristine, doxorubicin, cyclophosphamide, dactinomycin, ifosfamide and etoposide. Polish Pediatric Solid Tumors Group usually recommends CWS therapeutic protocols for the management of RMS. For group IV patients i.e., with disseminated tumor dis-ease, aggressive chemotherapy is usually recommended, subsequent with autologous myogenic stem cell transplantation but is still having worst prognosis [11].

The Radiation therapy is used in most of the RMS cases and its dose and fractionation schedule are individualized according to the therapeutic protocols. Surgical treatment and radiation therapy are reserved for patients of first-line treatment failure. According to American Therapeutic Protocols, surgery and radiation therapy are considered at earlier stages of treatment. Radiation dosage usually preferred is between 36-50.4 Gy, however, smaller dose can be used in group II patients with incomplete surgery. Patients with residual disease or with unresected tumor require higher radiation doses. The real challenge for radiation oncologists are the children under the age of 3-year, in whom the risk rate is significantly high. Because of many critical structures in the head and neck region, late effects of irradiation are frequent. In order to minimize the risk of radiation i.e., to increase the safety of radiation therapy, now a days conformal radiotherapy, intensity-modulated radiation therapy (IMRT), image guided radiation therapy (IGRT) or proton therapy are usually preferred [12]. Brachytherapy, now a days has also emerged with promising results, because of the fact that radiation dose given directly to the tumor bed are having lesser complications as compared to conventional radiotherapy and has shown good results particularly in RMS of the genitourinary tract and extremities.

Surgical management of RMS is an important component of the multifarious management strategy as complete resection and has the best prognosis. However, due to the complex anatomical structure of the head and neck region, it is extremely difficult to achieve margin free tumor resection. In addition, the RMS of the head and neck is already locally advanced in more than 50% of patients at the time of presentation [13]. Therefore, if the surgical resection is incomplete or the risk of disfigurement and loss of function is high, induction chemotherapy can be the choicest step and surgical intervention is limited for the diagnostic biopsy only [11]. Histopathological examinations of all the clinically suspected lymph nodes are strongly recommended. Patients who are excluded from the primary tumor resection may undergo second-look surgery after receiving neoadjuvant chemotherapy or chemoradiation. The most common surgical complication includes paralysis of trigeminal and facial nerves, compromised motility of the temporo-mandibular joint and cosmetic defects.

In terms of conventional chemotherapy, escalated chemotherapy regimen for non-metastatic RMS provided no survival advantage but adds toxicity when the ifosfamide, vincristine, and actinomycin D (IVA) schedule was compared with the six-drug combination (IVA plus carboplatin, epirubicin, and etoposide) [3]. At the same time, intravenous vinorelbine 25 mg/m2 on days 1, 8 and 15 of each 28-day cycle along with continuous low doses oral cyclophosphamide 25 mg/m2 showed fascinating re-sponse rate in RMS [14]. Further concurrent radiotherapy (in the range of 30.6–50.4 Gy) with irinotecan and carboplatin in RMS demonstrated favourable tolerability, efficacy, and local control [15]. Based on the immunology and genetic mapping, newer therapeutic approaches may provide important prognostic information and can be future revolution in the management of RMS [6].

Conclusion

The present case of 2-year male child is a very unusual and rare site of metastatic presentation of the RMS. CECT abdomen which is responsible for staging and extent of the disease, revealed a large heterogeneous mass in the retroperitoneum extending up to pelvis. Histopathology with immunocytochemistry finally established the diagnosis of RMS. Only about 13% of patients with RMS have evidence of metastatic disease at the time of the diagnosis. Patients with primary metastatic or recurrent RMS are still more pessimistic and have poor prognosis with EFS of 15%. Combination chemotherapy like VAC is the mainstay of treatment because complete resection is usually not feasible in most of the patients and radiation therapy is mostly used to control residual bulky or microscopic disease. The genetics of the tumor cells is the future for the disease which may provide important prognostic information. Finally, the authors conclude that retroperitoneal RMSs are extremely rare tumors with poor prognosis and only infinitesimal cases have been reported in the literature, hence the conclusions about treatment and prognosis are equivocal. However, the best approach for treating these malignant tumors is the collaboration between the paediatric surgeon, the pathologist, and the oncologists in order to optimize the better treatment outcomes for the best interest of the patient.

References

  1. Maurer HM, Gehan EA, Beltangady M, Crist W, Dickman PS, Donaldson SS. The Intergroup Rhabdomyosarcoma Study-II. Cancer. 1993:71:1904-22.
  2. Oberlin O, Rey A, Lyden E, Bisogno G, Stevens MC, Meyer WH, et al. Prognostic factors in metastatic rhabdomyosarcomas: results of a pooled analysis from United States and European cooperative groups. Journal of Clinical Oncology. 2008;26:2384-9.
  3. Oberlin O, Rey A, Sanchez de Toledo J, Martelli H, Jenney ME, Scopinaro M, et al. Randomized comparison of intensified six-drug versus standard three-drug chemotherapy for high-risk non-metastatic rhabdomyosarcoma and other chemotherapy-sensitive childhood soft tissue sarcomas: Long term results from the International Society of Pediatric Oncology MMT95 study. Journal of Clinical Oncology. 2012;30:2457-65.
  4. Miller RW, Young JL Jr, Novakovic B. Childhood cancer. Cancer. 1995;75(1 Suppl):395-405.
  5. Gordón-Núñez MA, Piva MR, Dos Anjos ED, Freitas RA. Orofacial rhabdomyosarcoma: Report of a case and review of the literature. Medicina Oral Patologia Oral y Cirugia Bucal. 2008;13:765-9.
  6. Sorensen PHB, Lynch JC, Qualman SJ, Tirabosco R, Lim JF, Maurer HM, et al. PAX3-FKHR and PAX7-FKHR gene fusions are prognostic indicators in alveolar rhabdomyosarcoma: A report from the Children’s Oncology Group. Journal of Clinical Oncology. 2002;20:2672-9.
  7. Breneman JC, Lyden E, Pappo AS, Link MP, Anderson JR, Crist WM. Prognostic factors and clinical outcomes in children and adolescents with metastatic rhabdomyosarcoma-a report from the Intergroup Rhabdomyosarcoma Study IV. Journal of Clinical Oncology. 2003; 21:78-84.
  8. Crist W, Gehan EA, Ragab AH, Diickman PS, Donaldson SS, Heyn R. The Third Intergroup Rhabdomyosarcoma Study. Journal of Clinical Oncology. 1995;13: 610-30.
  9. Maurer HM, Beltangady M, Gehan EA, Crist W, Hammond D, Hays DM. The Intergroup Rhabdomyosarcoma Study-I. A final report. Cancer. 1988;61:209-20.
  10. Mazzoleni S, Bisogno G, Garaventa A, Cecchetto G, Ferrari A, Sotti G, et al. Outcomes and prognostic factors after recurrence in children and adolescents with nonmetastatic rhabdomyosarcoma. Cancer. 2005;104:183-90.
  11. Peinemann F, Kroger N, Bartel C, Grouven U, Pittler M, Erttmann R, et al. High-dose chemotherapy followed by autologous stem cell transplantation for metastatic rhabdomyosarcoma – A systematic review. PLoS One. 2011;6:17127.
  12. Yock T, Schneider R, Friedmann A, Adams J, Fullerton B, Tarbell N. Proton radiotherapy for orbital rhabdomyosarcoma: clinical outcome and a dosimetric comparison with photons. International Journal of Radiation Oncology, Biology, Physics. 2005;63:1161-8.
  13. Turner JH, Richmon JD. Head and neck rhabdomyosarcoma: A critical analysis of population-based incidence and survival data. Otolaryngol Head Neck Surgery. 2011;145:967-73.
  14. Minard-Colin V, Ichante JL, Nguyen L, Paci A, Orbach D, Bergeron C, et al. Phase II study of vinorelbine and continuous low doses cyclophosphamide in children and young adults with a relapsed or refractory malignant solid tumour: Good tolerance profile and efficacy in rhabdomyosarcoma – A report from the Societe Francaise des Cancers et leucemies de l’Enfant et de l’adolescent (SFCE). European Journal of Cancer. 2012;48:2409-16.
  15. Dharmarajan KV, Wexler LH, Wolden SL. Concurrent radiation with irinotecan and carboplatin in intermediate- and high-risk rhabdomyosarcoma: A report on toxicity and efficacy from a prospective pilot phase II study. Pediatric Blood & Cancer. 2013; 60:242-7.

Author Info

Anil Kumar Dhull1*, Kamal Nain Rattan2, Vivek Kaushal1, Manas Dubey1 and Veena Gupta31Department of Radiation Oncology, Regional Cancer Centre, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
2Department of Pediatric Surgery, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
3Department of Pathology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Received Date: Nov 23, 2018 / Accepted Date: Mar 25, 2019 /

Copyright: © 2019 Anil Kumar Dhull et al. This is an open access paper distributed under the Creative Commons Attribution License. Journal of Biology and Today's World is published by Lexis Publisher; Journal p-ISSN 2476-5376; Journal e-ISSN 2322-3308. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

To spend time doing something; to consume or use spare time by doing something. I read to pass the time while waiting in the doctor's office. I passed the time of day by talking to Dave. See also: pass, time. McGraw-Hill Dictionary of American Idioms and Phrasal Verbs. What is a word for time passing.

Dr Anil Kumar

Vinegar is commonly used as an effective head lice treatment, but it is actually often misused.

Most people are told that it will remove both adult lice and head lice eggs. We’ll see that it’s not really true. The problem is, people who sell commercial anti-lice products take advantage of this to say that home remedies for head lice such as vinegar don’t work. This isn’t true, either.


What vinegar can do and cannot do for treating head lice

The truth is that vinegar will not kill adult head lice, because it simply lacks the properties to do so. The acid contained in vinegar might kill nymphs, though, which are young lice that cannot lay eggs yet.

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However, vinegar can really help getting rid of head lice eggs, called nits. A vinegar lice treatment combined with careful combing is definitely powerful to get rid of head lice eggs.

But if you also want to kill adult head lice, you’ll have to use another home remedy such as olive oil. Essential oils can also help; see our article on tea tree oil for lice.

So just remember:

Vinegar can help you get rid of nits or head lice eggs.

Vinegar can NOT help you get rid of adult head lice.

Why is vinegar effective to remove head lice eggs?

The word vinegar derives from the Old French vin aigre, meaning sour wine. Vinegar is the result of two biochemical processes: alcoholic fermentation, which converts natural sugars into alcohol, and acid fermentation, in which microorganisms present in the air we breathe, convert the alcohol into acetic acid.

This acid has antiseptic or germ killing properties. Vinegar usually has an acetic acid concentration of around 5% and is safe to use for head lice.

The acetic acid contained in vinegar will not dissolve the exoskeleton (the protective shell of nits) of lice eggs and therefore will not kill them.


However, it will help loosen the glue that holds the nits to the hair shaft so that the nits will no longer stick to the hair and will be easy to remove with a good nit comb.

What type of vinegar can we use to treat lice?

You can use different types of vinegar for head lice, such as white vinegar, wine vinegar (red or white), or apple cider vinegar.

1. White vinegar and head lice

White vinegar is distilled vinegar. It is plain acetic acid in water, either as a simple chemical mix (usually very cheap or cleaning grade vinegar) or obtained through fermentation of distilled alcohol. It has usually a 5% acidity level.

This vinegar is harsh and has a sharp flavor. It is cheaper than other types of vinegar, and it can readily be found in most grocery stores.

It may however contain additives and substances that may not be good for our scalp. Please be careful; if you are going to use vinegar on your head or your children’s head, make sure that the product is natural and safe to use.

Anil Kumar Md

2. Wine vinegar for head lice

  • White Wine Vinegar: this type of vinegar is light flavored and is used for cooking. Its color can vary from white to pale gold and its acidity level varies from 5% to 7%. It is made from the fermentation of real white wine, and thus retains much of its original white wine taste.
  • Red Wine Vinegar: it has been used for centuries for both medicinal and culinary purposes. Its color can vary from light rose to deep red and its acidity level also varies from 5% to 7%.

3. Apple cider vinegar

What apple cider vinegar to choose for head lice? Your best bet is to buy an apple cider vinegar which is not filtered, not pasteurized, and made from organic apples. This is because it will most of the time have a 5% acidity level, which is what you want.

A higher concentration would not be so safe to apply to your scalp, and a lower concentration would not be as effective to unglue the nits from your hair.


Is vinegar safe to use?

Vinegar is a natural organic by-product of fruits, vegetables and grains. It is therefore edible and biodegradable.

As long as it has been made naturally, it is perfectly safe for the environment, for family members and around young children. It doesn’t contain harmful toxic chemicals.

But if it has been highly processed and additives or other chemical substances have been used in manufacturing, it may not be safe to use. Please be careful and check with the manufacturer.

Vinegar will sting your eyes if sprayed directly into them, so direct contact with eyes should be avoided.

Warning: if your child has red marks on the scalp or has an irritated scalp (this can happen if the child has been infested for a while or if you have previously used a commercial lice killing shampoo), you want to avoid putting vinegar on the scalp, as it may irritate it too much.

How can you use vinegar to get rid of nits?

The process for a vinegar lice treatment is very simple and should be done in 3 steps:
  • Step #1: use a mixture of vinegar with water (half and half) to unglue the nits from the hairshaft. You should apply this vinegar and water mixture to your child’s hair, especially close to the scalp, behind the ears and in the neck area. Then, wait for a few minutes.
  • Step #2: you should now rinse off the vinegar with water. Then, you need to spend time combing all nits out. Click here for more info on How to use a lice comb.

    This is a crucial step, so don’t skip it, thinking that the vinegar will do the trick. It will NOT.

  • Step #3: repeat this process for two days or more until you can see no head lice eggs anymore and you are sure that all live nits are gone. Nits will hatch within 7 days of being laid, this is why you should really get rid of all live nits within a week from the date of your first vinegar treatment and combing out.
You may also be interested in reading:
Head Lice Treatment: What to Do When You Have Lice, about the following topics:
  • What You Should Know Before Applying Head Lice Treatments
  • Do Lice Treatments Work? What Research Says
  • Chemical Treatments for Head lice – What Research Says
  • Home Remedies for Head Lice – What Research Says
  • What Do Trusted Health Sources Say About Head Lice Treatments?
  • How to Use OTC Head Lice Treatment Products
  • How to Choose the Best Lice Shampoo
  • Head Lice Shampoos and Resistant Head Lice
  • Home Remedies and Natural Head Lice Treatments

It’s all on this page about head lice treatment.