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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Case report
Year : 2011 | Month : February | Volume : 5 | Issue : 1 | Page : 117 - 119

Calcaneal Ewing’s Sarcoma with Skip Metastases to the adjacent Tarsal Bones

YASIR SALAM SIDDIQUI, MOHAMMAD ZAHID, AAMIR BIN SABIR, NAIYER ASIF, GAURAV KUMAR, MERAJ AKHTAR

Dept of Orthopaedic Surgery, J. N. Medical College, A.M.U., Aligarh.

Correspondence Address :
Dr. Yasir Salam Siddiqui, Orthopaedic Registrar, Dept. of Orthopaedic
Surgery, Jawaharlal Nehru Medical College, Aligarh
Muslim University, Aligarh
E-mail: yassu98@gmail.com. Phone: +919837343400

Abstract

Ewing’s sarcoma (ES) is a malignant non-osteogenic primary tumour of the bone, which is mainly seen in the diaphysis of the long bones and in the flat bones of the pelvic girdles in young patients. In 30% of the cases, Ewing’s sarcoma is multicentric in origin and in 14-50% of the cases, multiple metastases are present at the time of diagnosis. Ewing’s Sarcoma of the calcaneum has been infrequently reported in literature.Skip metastases to the adjacent tarsal bones have been reported even more rarely. We wish to report a case of primary Ewing’s sarcoma of the calcaneum with skip metastases to the
adjacent tarsal bones, which was diagnosed by clinicoradiological examination and confirmed by histopathology.

Keywords

Ewing’s sarcoma, calcaneum, skip metastases

Ewing’s sarcoma is a malignant non-osteogenic primary tumour of the bone, which is mainly seen in the diaphysis of the long bones and in the flat bones of the pelvic girdles in young patients. Originally,
James Ewing described it in 1921, as a tumour arising from differentiated osseous mesenchymal cells; however, recent studies
suggest that Ewing’s tumour may be neuroectodermally derived from the primitive neural tissue (1).All these lesions (Ewing’s sarcoma and PNET) are now included in the same classification, the Ewing’s sarcoma family of tumors (EFTs). The EFT, in 85% of the cases, is associated with translocation t(11;22)(q24;q12). This fusion of the EWS gene on 22q12 with the FLI1 gene on 11q24, results in a chimeric fusion transcript,EWS-FLI1. In another 10-15% of the cases, the translocation t(21;12)(22;12), resulting in the EWS-ERG (Ets-related gene) fusion,is seen. The remainder of 1-5% of the cases shows other complex translocations. The peak incidence of Ewing’s sarcoma is noticed in the second decade of life, with a male preponderance of 1.6:1.It is an extremely anaplastic, round cell tumour, primarily arising in the intramedullary portion of the bone and metastases are not unusual (2).Ewing’s sarcoma demonstrates a predilection for the trunk and the long bones. In the truncal skeleton, the pelvis predominates,followed by the scapula, the vertebral column, the ribs and the clavicle. Of the long bones, the most common site is the femur,followed by the humerus, the tibia and the bones of the forearm, in that order (19).As opposed to osteosarcoma, Ewing’s sarcoma of the long bones tends to arise from the diaphysis, rather than from the metaphysis.
In 30% of the cases, Ewing’s sarcoma is multicentric in origin (3). In 14-50% of the cases, multiple metastases are present at the time of diagnosis (4).The management of Ewing’s sarcoma includes multiagent neoadjuvent chemotherapy, followed by enblock excision of the tumour mass. Surgical resection improves the local control of the disease. Operative treatment may be particularly applicable in the foot (5).Postoperative radiotherapy is given if there is doubt of tumour residual.The prognosis is poor and the tumour commonly metastasizes to the lungs and to other bones. The most unfavourable prognostic factor in Ewing’s sarcoma is the presence of distant metastases at diagnosis. Other unfavourable prognostic factors include an age which is older than 10 years, a size larger than 200 ml,more central lesions (as in the pelvis or spine), and poor response to chemotherapy (6).Ewing’s sarcoma is of rare occurrence in the small bones of the
hand and the feet. We wish to report a case of Primary Ewing’s
sarcoma of the calcaneum with skip metastasis to the adjacent tarsal
bones, which was diagnosed by clinicoradiological examination
and confirmed by histopathology.

Case Report

An 8-year-old boy presented with a swelling of seven months duration
in the region of his left calcaneum. It started with a small painful
swelling in the region, which went on to rapidly increase in size,
attaining its present size at the time of admission (Table/Fig 1).and shiny, with visible dilated subcutaneous veins. The rest of the skeletal survey was normal. All the blood parameters were normal,
except the alkaline phosphatase level, which was found to be raised. The initial radiograph of the calcaneum, taken four months after the appearance of the swelling, showed a sclerotic lesion in the calcaneum, with soft tissue mass and minimal focal increase in the density of the talus and the cuboid (Table/Fig 2). The initial graph raised doubts about the skip metastases to the adjoining tarsal bones. The radiograph of the ankle, taken at presentation (seven months after the swelling), showed the clear cut involvement of the adjacent tarsal bones – the talus and the cuboid (Table/Fig 3).
Fine needle aspiration cytology from the swelling was consistent
with the diagnosis of Ewing’s Sarcoma. CT scan of the chest was
normal. The patient was advised adjuvant chemotherapy and above–the-knee amputation after explaining the prognosis of the disease, but the patient and his parents refused. Hence the patient was managed by Chemotherapy only.

Discussion

Ewing’s Sarcoma of the calcaneum has been infrequently reported
in literature. Since 1921, Cook has reported 29 cases of Ewing’s
sarcoma of the calcaneum in the literature (7). These rare cases are usually misdiagnosed, leading to treatment delay, which is detrimental to the outcome of the disease. Clinicoradiologically, Ewing’s sarcomas can be misinterpreted as osteomyelitis, cartilaginous tumours, giant cell lesions, lymphomas, and osteosarcomas (8) and their differentiation often requires extensive evaluation by using different imaging modalities. The classical radiological presentation of Ewing’s sarcoma is a destructive lesion in the diaphysis of the long bones, with an onionskin periosteal reaction. A universal feature of the disease is the presence of a large soft tissue mass which is relatively larger than the extent of the bone changes. Sometimes, the only apparent change in a radiograph is the presence of a mass,cortical erosion or periosteal reaction being hardly visible (9).The radiographical features in the hand and feet involvement are generally those of typical Ewing’s sarcoma: permeation, soft-tissue mass, and, frequently, coupled with a sclerotic reaction. However, with the exception of sclerosis, the features suggesting bone reaction
and slow tumour growth in these patients were distinctly unusual, as compared to Ewing’s sarcoma in general (10).The lack of a lamellated or speculated periosteal reaction and the absence of cortical thickening were more commonly seen in the ES
of the hands and feet than in other locations (11).
The absence of a periosteal reaction and the lack of cortical thickening were also noted in our patient. The lesions affecting the tarsal bones, more often demonstrate atypical radiographical features
(8).These atypical radiographical appearances may play a role in the reported delay in the diagnosis of Ewing’s sarcoma within the tarsal bones. CT or MR will optimally delineate the osseous and the soft tissue extent of the tumour, which is often much greater than may be appreciated on conventional radiographs.In Ewing’s sarcoma, the metastatic pattern may be pulmonary involvement alone, bone or bone marrow spreading alone, skips metastases,or combined metastatic disease (12),(13).
The imaging features of the local spread of Ewing’s sarcoma involving
the small bones into the adjacent bone, have been described in
the literature very infrequently. Agarwal et al has reported calcaneal Ewing’s sarcoma with metastases to the ipsilateral tibia and the fibula (14).
Shirley et al (15) reviewed 10 patients with ES of the foot: five in the calcaneus, one in the talus, two in the metatarsals and two in the phalanges. With the exception of those patients with lesions in the calcaneum, the prognosis for disease free survival was excellent.The location of the lesion is important, since in the reported cases in the literature, the lesions of the calcaneum were found to fare poorly (15).In our patient, it was not possible to clearly determine the exact local extent of the tumour on conventional radiography in the beginning of disease. However, the initial radiograph raised doubt about the skip lesions in the talus and the cuboid (Table/Fig 2). As the patient reported late to our institution, conventional radiography at presentation, revealed the clear cut involvement of the talus and the cuboid, along with the lesion in the calcaneum. MRI, due to its superior contrast resolution and multi-planar capabilities, is more sensitive
than other imaging techniques, especially for the investigation
of tumour spread to the bony structures and the bone marrow.
Hence, MRI should always be performed in the analysis of Ewing’s
sarcoma, since it allows the accurate evaluation of the tumour extent,which is critical for its management (7),(16),(17).According to a retrospective study concerning 235 patients with
non-metastatic Ewing’s sarcoma of the bone, 15 patients with a
skip lesion were identified at diagnosis. But the skip lesions were
located in the adjacent juxta-articular bone in only 2 cases (18),as was seen in our patient. Skip lesions in patients with otherwise non-metastatic skeletal Ewing’s sarcoma, may be of the same consequence as the molecular detection of the marrow metastases and possibly confer a worse prognosis. Newer imaging modalities (for example PET) and careful staging work-up may indicate that skip metastases in Ewing’s sarcoma are more common than previously suspected (18).

Conclusion

This case report confirms that the routine radiological management
of Ewing’s sarcoma should include conventional radiography, CT or
MRI of the affected part to rule out skip lesions, as skip lesions are often missed out initially. CT scan of the chest should also be done to detect lung metastases. CT and MRI are essential in the determination of the true extent of the tumour. It is important to bear in mind that the most unfavourable prognostic factor in Ewing’s
sarcoma, is the presence of distant metastases at the time of diagnosis.
Early recognition of an atypical appearance and the location of Ewing’s sarcoma are necessary for its adequate treatment.

References

1.
Yalein S, Turoglu T, Ozdamar S et al. Ewing's tumor of the mandible: Oral surgery oral med oral pathol 1993; 76: 362-7.
2.
Pritchard DJ, Dahlin DC, Dauphine RT et al. Ewing’s Sarcoma : A clinicopathological and statistical analysis of patients surviving five years or longer. J Bone Joint Surg 1975 ; 57-A : 10-16.
3.
Ewing J. Diffuse endothelioma of bone. Proc NY Pathol Soc. 1921; 21:17-24.
4.
Trigg ME, Glaubiger D. The frequency of isolated CNS involvement in Ewings Sarcoma.Cancer. 1981; 49: 2404.
5.
Leeson MC, Smith MJ. Ewing’s sarcoma of the foot. Foot Ankle 1989; 10:147-151.
6.
Gehan, E. A.; Nesbit, M. E. . JR.; Burgert, E. 0. , JR.: Viettit. J.: Tefft. M.: Perez, C. A.: Kissane, J.; and Hempel, C.: Prognostic Factors in Children with Ewing’s Sarcoma. Nat. Cancer Inst. Monog. 1981;56: 273-278.
7.
Cook M A, Manfredi O L. Ewing's sarcoma of the hand: a case report: Bulletin Hospital for Joint Diseases 1996; Vol 55, N° 2: 75-7.
8.
Baraga JJ, Amarami KK, Swee RG, Wold L, Unni KK: Radiographic features of Ewing’s sarcoma of the bones of the hand and feet. Skeletal Radiol. 2001 30: 121-126.
9.
Henk CB, Gramp PS, Wiesbauer P et al. Ewing sarcoma. Diagnostic imaging: Radiologe 1998 Jun; 38(6): 509-22.
10.
Reinus WR, Gilula LA, Shirley SK et al. Radiographic appearance of Ewing sarcoma of the hands and feet : report from the Intergroup Ewing Sarcoma Study. Am J Roentgenology 1985 ; 144 : 331-336.
11.
Escobedo EM, Bjorkengren AG, Moore SG. Ewing’s sarcoma of the hand. Am J Roentgenology 1992 ; 159 : 101-102.
12.
Wilkins RM, Pritchard DJ, Burgert EO, Unni K: Ewing’s sarcoma of bone: experience with 140 patients. Cancer. 1986; 58:2551-2555.
13.
Davies AM, Makwana NK, Grimer RJ, Carter SR: Skip metastases in Ewing’s sarcoma: a report of three cases. Skeletal Radiol. 1997; 26: 379-384.
14.
Agarwal N , Sabir AB. Ewing’s sarcoma of the calcaneus with metastases to the tibia and fibula. Acta Orthop. Belg., 2008, 74, 270-272.
15.
Shirley SK, Askin FB, Gilula LA et al. Ewing’s sarcoma in bones of the hands and feet : A clinicopathologic study and review of the literature. J Clin Oncol 1985; 3 : 686-697.
16.
Zelazny A, Reinus WR, Wilson AJ: Quantitative analysis of the plain radiographic appearance of Ewing’s sarcoma of bone. Invest Radiol. 1997; 32: 59-65.
17.
Dyke JP, Panicek DM, Healey JH, Meyers PA, Huvos AG,Schwartz LH, Thaler HT, Tofts PS, Gorlick R, Koutcher JA, Ballon D: Osteogenic and Ewing sarcomas: estimation of necrotic fraction during induction chemotherapy with dynamic contrastenhanced MR imaging. Radiology. 2003; 228: 271-278.
18.
Jiya TU, Wuisman PI: Long-term follow-up of 15 patients with non-metastatic Ewing's sarcoma and a skip lesion. Acta Orthop. 2005 Dec;76(6):899-903.
19.
Yukihide Iwamoto: Diagnosis and Treatment of Ewing’s Sarcoma. Jpn J Clin Oncol 2007;37(2)79–89.

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