The solitary pulmonary nodule remains a common clinical problem. The essential question is whethe... more The solitary pulmonary nodule remains a common clinical problem. The essential question is whether the lesion is malignant or not. This discussion presents the clinical practice and looks at the problem. Design: Didactic. Setting: Academic tertiary-care hospital. Patients: Prospective thoracic database. Interventions: Minimally invasive technique. Results: The workup and treatment of the solitary pulmonary nodule is presented with particular emphasis on the role of minimally invasive techniques. A small single-institution series is referenced. Conclusions: The approach is safe and highly effective in diagnosing and often in treating solitary pulmonary nodules.
Purpose: A Phase 2 trial of stereotactic radiotherapy and in situ cytotoxic virus therapy in pati... more Purpose: A Phase 2 trial of stereotactic radiotherapy and in situ cytotoxic virus therapy in patients with metastatic triple-negative breast cancer (mTNBC) followed by pembrolizumab (STOMP) was designed to evaluate dual approach of enhancing single-agent immune checkpoint blockade with adenovirus-mediated expression of herpes-simplex-virus thymidine-kinase (ADV/HSV-tk) plus valacyclovir gene therapy and stereotactic body radiotherapy (SBRT) in patients with mTNBC. Patients and Methods: In this single-arm, open-label Phase 2 trial, patients with mTNBC were treated with ADV/HSV-tk [5 × 1011 virus particles (vp)] intratumoral injection, followed by SBRT to the injected tumor site, then pembrolizumab (200 mg, every 3 weeks). The primary endpoint was clinical benefit rate [CBR; complete response (CR), partial response (PR), or stable disease (SD) ≥ 24 weeks per RECIST version1.1 at non-irradiated site]. Secondary endpoints included duration on treatment (DoT), overall survival (OS), and ...
1079 Background: Pembrolizumab, stereotactic body radiotherapy (SBRT), and viral vector-based gen... more 1079 Background: Pembrolizumab, stereotactic body radiotherapy (SBRT), and viral vector-based gene therapy such as adenovirus-mediated expression of herpes simplex virus thymidine kinase (ADV/HSV-tk) plus ganciclovir have each shown antitumor immune activity. The combination of those modalities may represent a window of opportunity to enhance pembrolizumab efficacy in mTNBC patients. Methods: In this single-arm, open-label phase II trial, mTNBC patients were treated with in situ oncolytic ADV/HSV-tk (5 x 1011 vp) intratumoral injection, followed by SBRT to the injected tumor site, then pembrolizumab until progression or intolerable toxicity. Response was assessed in non-irradiated metastatic sites. The primary end point was clinical benefit rate (CR, PR and SD per RECIST version1.1). Secondary endpoints included duration on treatment (DoT) and safety. Immune correlative analysis with peripheral blood CYTOF (D1 baseline, D7 and D38), and tissue imaging mass cytometry (IMC) with 35 ce...
9115 Background: The introduction of immunotherapy has altered the treatment paradigm for metasta... more 9115 Background: The introduction of immunotherapy has altered the treatment paradigm for metastatic non-small cell cancer (mNSCLC). Unfortunately, many patients with mNSCLC have limited or no benefit from immune checkpoint inhibitors (ICIs). A variety of approaches have been explored to augment the efficacy of ICIs. Our study’s aim was to determine whether the addition of stereotactic body radiation therapy (SBRT) and intratumoral injection of the oncolytic virus ADV/HSV-tk (adenovirus-mediated expression of herpes simplex virus thymidine kinase) to a monoclonal antibody targeting programmed cell death-1 (PD-1) would improve the ICI’s efficacy in the treatment of mNSCLC. Methods: In this single-arm, open-label phase II study, patients with mNSCLC (squamous or non-squamous) who were ICI-naive or who were previously treated with a maximum of one line of therapy that included an ICI received an intratumoral injection of ADV/HSV-tk (5 x 1011 vp) followed by SBRT (30 Gy in 5 fractions) ...
Objective To estimate the intra-observer repeatability of shear wave elastography in the UCL of t... more Objective To estimate the intra-observer repeatability of shear wave elastography in the UCL of the elbow, and to compare shear wave velocities between dominant and non-dominant arms. Materials and methods Twenty elbows in ten healthy volunteers were evaluated [five males, five females; mean age, 31.8 ± 10.3 years]. Shear wave velocity was measured on three separate days during the span of 1 week utilizing a linear 18-MHz transducer. Elastograms were obtained until ten ROIs were drawn, not drawing more than two ROIs on any elastogram. Elastograms were considered diagnostic if any portion of the UCL was colored in and free of boundary artifacts. Median velocity and interquartile range were recorded. A result was considered reliable if the IQR/median ratio of the ten measurements was < 0.3. Results IQR/median was < 0.3 in 88% of sessions, although in 28% of sessions fewer than 60% of elastograms were diagnostic. The ICC was 0.05 (95% CI; − 0.18-0.36; poor). Repeatability coefficient (95% limits of agreement) was 1.95 m/s (95% CI; 1.61-2.37 m/s). Mean velocity in dominant arms was 5.14 ± 0.53 m/s and 5.24 ± 0.39 m/s in non-dominant (p = 0.558). Conclusions Mean shear wave velocity was similar between dominant and non-dominant arms. Although repeatability was poor as assessed by ICC, the repeatability coefficient may be a more useful indicator of clinical utility once shear wave velocities in diseased ligaments are explored. Future studies should therefore evaluate velocities in diseased ligaments and develop techniques to improve elastogram quality.
International Journal of Research in Dermatology, 2019
Background: Psoriasis is a chronic inflammatory disorder with defective proliferation and differe... more Background: Psoriasis is a chronic inflammatory disorder with defective proliferation and differentiation of keratinocytes. It is associated with metabolic syndrome i.e. dyslipidemia, hypertension, obesity, cardiovascular diseases and insulin resistance. The high incidence of cardiovascular events in psoriasis is highly associated with abnormal lipid metabolism. This case-control study was done in North Indian medical institute to investigate the levels of serum lipids in psoriasis patients taking in account various parameters like weight, height, body mass index, blood pressure and diabetes. Methods: We assessed the fasting lipid profile in 48 psoriasis patients and 48 healthy, age and sex matched controls. Results: The study found significant elevation (p<0.05) of serum total cholesterol, triglycerides, low density lipoproteins (LDL) and very low density lipoproteins (VLDL) in psoriasis patients compared to controls. The levels of high density lipoproteins (HDL) were also significantly lower (p<0.05) in psoriasis patients. Conclusions: This study suggests that psoriasis is a high risk disorder for cardiovascular mortality and morbidity because of its association with dyslipidemia.
The significant improvement of patient outcomes from minimally invasive lung surgery has led to t... more The significant improvement of patient outcomes from minimally invasive lung surgery has led to the development of advanced lung nodule localization techniques to help manage patients with small suspicious lung nodules or to help resect patients with small pulmonary metastases. However, there are no clear computed tomography (CT) criteria to guide the use of advanced localization techniques for this group of patients. We conducted a retrospective chart review of patients who had undergone initial wedge resection of single or multiple lung nodules. We collected demographics, surgical information and surgical outcomes as well as CT scan features. Multiple logistic regression was performed to determine which factors were most predictive of the need for advanced localization techniques. A total of 45 patients (73%) were resected by direct identification alone while 17 patients (27%) required advanced localization techniques. Of those requiring advanced localization, 11 patients had cone...
Cardiovascular and interventional radiology, Jan 28, 2016
To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for... more To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores. The medical records of 25 patients referred for renal artery embolization after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of tumors, RENAL nephrometry scores, angiographic abnormalities, technical and clinical outcomes, and estimated glomerular filtration rates (eGFRs) after embolization. Twenty-four patients had primary renal tumors, while 1 patient had a pancreatic tumor invading the kidney. Multiple tumors were resected in 4 patients. Most patients (92 %) were symptomatic, presenting with gross hematuria, flank pain, or both. Angiography revealed PSA with (n = 5) or without (n = 20) AV fistulae. Sixteen patients (64 %) had multiple PSA involving multiple renal vessels. Higher RENAL nephrometry scores were associated w...
Purpose-The goal of this study is to describe CT findings in patients with clinically proven temp... more Purpose-The goal of this study is to describe CT findings in patients with clinically proven temporal bone osteoradionecrosis (TB-ORN). Methods and materials-CT scans of twenty patients were retrospectively evaluated for bony and soft tissue abnormalities. Clinical severity was graded based on level of therapy administered: mild (observation), moderate (antibiotics/hyperbaric oxygen), or severe (surgery). Results-Radiation dose to the primary tumor ranged from 30 to 75.6 Gy. Time to onset of ORN from completion of radiation therapy was 2 to 22 years (median=7yrs). Clinical findings: Exposed bone=20/20, otorrhea=17/20, hearing loss=11/20, otalgia=10/20, facial nerve paralysis=2/20, gait imbalance=2/20. CT findings: EAC erosions=18/20, mastoid effusion=18/20, mastoid bony coalescence=5/20, enhancing soft tissue=6/20, soft tissue gas=6/20, temporomandibular joint/condylar erosion=3/20. 3 patients developed an abscess. Conclusion-Mastoid effusion and EAC erosions are commonly seen with TB-ORN. Clinically moderate or severe cases of TB-ORN are more likely to demonstrate enhancing soft tissue (p=0.002), soft tissue gas (p=0.002), and temporomandibular joint involvement (p=0.07).
PURPOSE To describe the presentation, endovascular management, outcome, and effect on renal funct... more PURPOSE To describe the presentation, endovascular management, outcome, and effect on renal function of selective transarterial embolization of renal artery pseudoaneurysms and arteriovenous (AV) fistulae in patients following open or laparoscopic partial nephrectomy. METHOD AND MATERIALS The medical and imaging records of 25 patients who were referred for embolization of renal artery pseudoaneurysms or AV fistulae after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of primary tumors, presenting symptoms, number and type of angiographic abnormalities, embolization technical details, outcome, and estimated glomerular filtration rates (eGFRs) prior to and at multiple time points following embolization. RESULTS 24 patients had primary renal tumors, 1 patient had a pancreatic tumor directly invading the kidney. The median time between surgery and presentation was 11 days (range, 1 day to 502 days; mean, 38 days). Most patients (n=23; 92%...
The solitary pulmonary nodule remains a common clinical problem. The essential question is whethe... more The solitary pulmonary nodule remains a common clinical problem. The essential question is whether the lesion is malignant or not. This discussion presents the clinical practice and looks at the problem. Design: Didactic. Setting: Academic tertiary-care hospital. Patients: Prospective thoracic database. Interventions: Minimally invasive technique. Results: The workup and treatment of the solitary pulmonary nodule is presented with particular emphasis on the role of minimally invasive techniques. A small single-institution series is referenced. Conclusions: The approach is safe and highly effective in diagnosing and often in treating solitary pulmonary nodules.
Purpose: A Phase 2 trial of stereotactic radiotherapy and in situ cytotoxic virus therapy in pati... more Purpose: A Phase 2 trial of stereotactic radiotherapy and in situ cytotoxic virus therapy in patients with metastatic triple-negative breast cancer (mTNBC) followed by pembrolizumab (STOMP) was designed to evaluate dual approach of enhancing single-agent immune checkpoint blockade with adenovirus-mediated expression of herpes-simplex-virus thymidine-kinase (ADV/HSV-tk) plus valacyclovir gene therapy and stereotactic body radiotherapy (SBRT) in patients with mTNBC. Patients and Methods: In this single-arm, open-label Phase 2 trial, patients with mTNBC were treated with ADV/HSV-tk [5 × 1011 virus particles (vp)] intratumoral injection, followed by SBRT to the injected tumor site, then pembrolizumab (200 mg, every 3 weeks). The primary endpoint was clinical benefit rate [CBR; complete response (CR), partial response (PR), or stable disease (SD) ≥ 24 weeks per RECIST version1.1 at non-irradiated site]. Secondary endpoints included duration on treatment (DoT), overall survival (OS), and ...
1079 Background: Pembrolizumab, stereotactic body radiotherapy (SBRT), and viral vector-based gen... more 1079 Background: Pembrolizumab, stereotactic body radiotherapy (SBRT), and viral vector-based gene therapy such as adenovirus-mediated expression of herpes simplex virus thymidine kinase (ADV/HSV-tk) plus ganciclovir have each shown antitumor immune activity. The combination of those modalities may represent a window of opportunity to enhance pembrolizumab efficacy in mTNBC patients. Methods: In this single-arm, open-label phase II trial, mTNBC patients were treated with in situ oncolytic ADV/HSV-tk (5 x 1011 vp) intratumoral injection, followed by SBRT to the injected tumor site, then pembrolizumab until progression or intolerable toxicity. Response was assessed in non-irradiated metastatic sites. The primary end point was clinical benefit rate (CR, PR and SD per RECIST version1.1). Secondary endpoints included duration on treatment (DoT) and safety. Immune correlative analysis with peripheral blood CYTOF (D1 baseline, D7 and D38), and tissue imaging mass cytometry (IMC) with 35 ce...
9115 Background: The introduction of immunotherapy has altered the treatment paradigm for metasta... more 9115 Background: The introduction of immunotherapy has altered the treatment paradigm for metastatic non-small cell cancer (mNSCLC). Unfortunately, many patients with mNSCLC have limited or no benefit from immune checkpoint inhibitors (ICIs). A variety of approaches have been explored to augment the efficacy of ICIs. Our study’s aim was to determine whether the addition of stereotactic body radiation therapy (SBRT) and intratumoral injection of the oncolytic virus ADV/HSV-tk (adenovirus-mediated expression of herpes simplex virus thymidine kinase) to a monoclonal antibody targeting programmed cell death-1 (PD-1) would improve the ICI’s efficacy in the treatment of mNSCLC. Methods: In this single-arm, open-label phase II study, patients with mNSCLC (squamous or non-squamous) who were ICI-naive or who were previously treated with a maximum of one line of therapy that included an ICI received an intratumoral injection of ADV/HSV-tk (5 x 1011 vp) followed by SBRT (30 Gy in 5 fractions) ...
Objective To estimate the intra-observer repeatability of shear wave elastography in the UCL of t... more Objective To estimate the intra-observer repeatability of shear wave elastography in the UCL of the elbow, and to compare shear wave velocities between dominant and non-dominant arms. Materials and methods Twenty elbows in ten healthy volunteers were evaluated [five males, five females; mean age, 31.8 ± 10.3 years]. Shear wave velocity was measured on three separate days during the span of 1 week utilizing a linear 18-MHz transducer. Elastograms were obtained until ten ROIs were drawn, not drawing more than two ROIs on any elastogram. Elastograms were considered diagnostic if any portion of the UCL was colored in and free of boundary artifacts. Median velocity and interquartile range were recorded. A result was considered reliable if the IQR/median ratio of the ten measurements was < 0.3. Results IQR/median was < 0.3 in 88% of sessions, although in 28% of sessions fewer than 60% of elastograms were diagnostic. The ICC was 0.05 (95% CI; − 0.18-0.36; poor). Repeatability coefficient (95% limits of agreement) was 1.95 m/s (95% CI; 1.61-2.37 m/s). Mean velocity in dominant arms was 5.14 ± 0.53 m/s and 5.24 ± 0.39 m/s in non-dominant (p = 0.558). Conclusions Mean shear wave velocity was similar between dominant and non-dominant arms. Although repeatability was poor as assessed by ICC, the repeatability coefficient may be a more useful indicator of clinical utility once shear wave velocities in diseased ligaments are explored. Future studies should therefore evaluate velocities in diseased ligaments and develop techniques to improve elastogram quality.
International Journal of Research in Dermatology, 2019
Background: Psoriasis is a chronic inflammatory disorder with defective proliferation and differe... more Background: Psoriasis is a chronic inflammatory disorder with defective proliferation and differentiation of keratinocytes. It is associated with metabolic syndrome i.e. dyslipidemia, hypertension, obesity, cardiovascular diseases and insulin resistance. The high incidence of cardiovascular events in psoriasis is highly associated with abnormal lipid metabolism. This case-control study was done in North Indian medical institute to investigate the levels of serum lipids in psoriasis patients taking in account various parameters like weight, height, body mass index, blood pressure and diabetes. Methods: We assessed the fasting lipid profile in 48 psoriasis patients and 48 healthy, age and sex matched controls. Results: The study found significant elevation (p<0.05) of serum total cholesterol, triglycerides, low density lipoproteins (LDL) and very low density lipoproteins (VLDL) in psoriasis patients compared to controls. The levels of high density lipoproteins (HDL) were also significantly lower (p<0.05) in psoriasis patients. Conclusions: This study suggests that psoriasis is a high risk disorder for cardiovascular mortality and morbidity because of its association with dyslipidemia.
The significant improvement of patient outcomes from minimally invasive lung surgery has led to t... more The significant improvement of patient outcomes from minimally invasive lung surgery has led to the development of advanced lung nodule localization techniques to help manage patients with small suspicious lung nodules or to help resect patients with small pulmonary metastases. However, there are no clear computed tomography (CT) criteria to guide the use of advanced localization techniques for this group of patients. We conducted a retrospective chart review of patients who had undergone initial wedge resection of single or multiple lung nodules. We collected demographics, surgical information and surgical outcomes as well as CT scan features. Multiple logistic regression was performed to determine which factors were most predictive of the need for advanced localization techniques. A total of 45 patients (73%) were resected by direct identification alone while 17 patients (27%) required advanced localization techniques. Of those requiring advanced localization, 11 patients had cone...
Cardiovascular and interventional radiology, Jan 28, 2016
To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for... more To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores. The medical records of 25 patients referred for renal artery embolization after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of tumors, RENAL nephrometry scores, angiographic abnormalities, technical and clinical outcomes, and estimated glomerular filtration rates (eGFRs) after embolization. Twenty-four patients had primary renal tumors, while 1 patient had a pancreatic tumor invading the kidney. Multiple tumors were resected in 4 patients. Most patients (92 %) were symptomatic, presenting with gross hematuria, flank pain, or both. Angiography revealed PSA with (n = 5) or without (n = 20) AV fistulae. Sixteen patients (64 %) had multiple PSA involving multiple renal vessels. Higher RENAL nephrometry scores were associated w...
Purpose-The goal of this study is to describe CT findings in patients with clinically proven temp... more Purpose-The goal of this study is to describe CT findings in patients with clinically proven temporal bone osteoradionecrosis (TB-ORN). Methods and materials-CT scans of twenty patients were retrospectively evaluated for bony and soft tissue abnormalities. Clinical severity was graded based on level of therapy administered: mild (observation), moderate (antibiotics/hyperbaric oxygen), or severe (surgery). Results-Radiation dose to the primary tumor ranged from 30 to 75.6 Gy. Time to onset of ORN from completion of radiation therapy was 2 to 22 years (median=7yrs). Clinical findings: Exposed bone=20/20, otorrhea=17/20, hearing loss=11/20, otalgia=10/20, facial nerve paralysis=2/20, gait imbalance=2/20. CT findings: EAC erosions=18/20, mastoid effusion=18/20, mastoid bony coalescence=5/20, enhancing soft tissue=6/20, soft tissue gas=6/20, temporomandibular joint/condylar erosion=3/20. 3 patients developed an abscess. Conclusion-Mastoid effusion and EAC erosions are commonly seen with TB-ORN. Clinically moderate or severe cases of TB-ORN are more likely to demonstrate enhancing soft tissue (p=0.002), soft tissue gas (p=0.002), and temporomandibular joint involvement (p=0.07).
PURPOSE To describe the presentation, endovascular management, outcome, and effect on renal funct... more PURPOSE To describe the presentation, endovascular management, outcome, and effect on renal function of selective transarterial embolization of renal artery pseudoaneurysms and arteriovenous (AV) fistulae in patients following open or laparoscopic partial nephrectomy. METHOD AND MATERIALS The medical and imaging records of 25 patients who were referred for embolization of renal artery pseudoaneurysms or AV fistulae after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of primary tumors, presenting symptoms, number and type of angiographic abnormalities, embolization technical details, outcome, and estimated glomerular filtration rates (eGFRs) prior to and at multiple time points following embolization. RESULTS 24 patients had primary renal tumors, 1 patient had a pancreatic tumor directly invading the kidney. The median time between surgery and presentation was 11 days (range, 1 day to 502 days; mean, 38 days). Most patients (n=23; 92%...
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Papers by Nakul Gupta