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Subject: A pragmatic clinicopathobiological grouping/staging system for gliomas: Proposal of the Indian TNM subcommittee on brain tumors Gupta T, Sarin R, Jalali R, Sharma S, Kurkure P, Goel A Neurol India
Date: Fri, 31 Jul 2009 17:47:23 +0200
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Helvetica, sans-serif
}
.body {
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.PrePublication {
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FONT-SIZE: 11px; BORDER-LEFT: #a6adc4 1px solid; COLOR: #464646; =
BORDER-BOTTOM: #a6adc4 1px solid; FONT-FAMILY: Arial, Verdana, =
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FONT-SIZE: 11px; BORDER-LEFT: #a6adc4 1px solid; LINE-HEIGHT: 135%; =
BORDER-BOTTOM: #a6adc4 1px solid; FONT-FAMILY: Arial, Verdana, =
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}
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FONT-FAMILY: Verdana,Arial, Helvetica, sans-serif; BACKGROUND-COLOR: =
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.Highlight {
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}
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Verdana, Helvetica, sans-serif
}
.tochead {
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}
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}
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.HighlightAbstract {
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}
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}
.toctab {
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Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff
}
.articlepage {
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BORDER-BOTTOM: #a6c4e1 1px solid; FONT-FAMILY: Verdana, Arial, =
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}
.parameter {
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}
.parameterhead {
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}
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}
.pageHead {
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}
.other {
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}
.sTitle {
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}
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}
.empty {
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BACKGROUND-COLOR: #ffffff
}
.footer {
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}
.sj {
	BORDER-RIGHT: #f8c301 1px solid; BORDER-TOP: #f8c301 1px solid; =
FONT-SIZE: 11px; BORDER-LEFT: #f8c301 1px solid; COLOR: #0000ff; =
BORDER-BOTTOM: #f8c301 1px solid; FONT-FAMILY: Arial, Verdana, =
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.bl {
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------=_NextPart_000_0000_01CA1206.F5B230C0
Content-Type: text/css;
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Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.neurologyindia.com/templates/current_l.css

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A:visited {
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}
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------=_NextPart_000_0000_01CA1206.F5B230C0
Content-Type: text/css;
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Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.neurologyindia.com/templates/current_l.css

A {
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------=_NextPart_000_0000_01CA1206.F5B230C0
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Content-Transfer-Encoding: quoted-printable
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<HTML><HEAD><TITLE>A pragmatic clinicopathobiological grouping/staging =
system for gliomas: Proposal of the Indian TNM subcommittee on brain =
tumors Gupta T, Sarin R, Jalali R, Sharma S, Kurkure P, Goel A Neurol =
India</TITLE>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Dwindows-1252">
<META=20
content=3D"Neurol India, full-text, online, electronic, e-journal, free =
access, open access, online submission"=20
name=3Dkeywords>
<META=20
content=3D" Neurol India is an peer-reviewed biomedical periodical of =
Neurological Society of India."=20
name=3Ddescription><!--DC META DATA START-->
<META=20
content=3D"A pragmatic clinicopathobiological grouping/staging system =
for gliomas: Proposal of the Indian TNM subcommittee on brain tumors"=20
name=3DDC.Title><LINK =
href=3D"http://purl.org/metadata/dublin_core_elements#title"=20
rel=3DSCHEMA.dc>
<META content=3DGupta name=3DDC.Creator><LINK=20
href=3D"http://purl.org/metadata/dublin_core_elements#creator" =
rel=3DSCHEMA.dc>
<META content=3D"Gliomas, prognosis, staging classification" =
name=3DDC.Subject>
<META=20
content=3D"<b>Background:</b>  There is no universally accepted staging =
system for primary brain tumors wherein prognostication is mainly based =
on complex composite indices<b> . Aim:</b>  To develop a simple, =
pragmatic, and widely applicable grouping/staging system for gliomas, =
the most common primary brain tumor. <b> Materials and Methods:</b>  An =
expert neurooncology panel with representation from radiation oncology, =
neurosurgery, pathology, radiology, and medical oncology had several =
rounds of discussion on issues pertinent to brain tumor staging. The =
trade off was between the accuracy of prognostic categorization and a =
pragmatic, widely applicable approach. <b> Results and =
Recommendations:</b>  The Tumor-Node-Metastasis staging was considered =
irrelevant for gliomas that seldom metastasize to lymphatics or outside =
the neuraxis. Instead, a 4-point staging/grouping system is proposed, =
using histological grade as the main prognostic variable and at least =
one stage migration based on other unfavorable features such as tumor =
location (brainstem); age (<5 years for all grades, >50 years for =
high-grade, and >40 years for low-grade gliomas); poor neurological =
performance status (NPS 2-4); multicentricity and/or gliomatosis; and =
adverse biological parameters (proliferative index, angiogenesis =
markers, apoptotic index, cytogenetic abnormalities, and molecular =
markers). <b> Conclusion:</b>  In absence of a grouping/staging system =
for primary brain tumors, prognostification is mostly based on complex =
composite indices. The proposed clinicopathobiological grouping/staging =
system for gliomas is a simple, pragmatic, and user-friendly tool with a =
potential to fulfill the objectives of staging classification."=20
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          <TD width=3D"100%" colSpan=3D3><FONT =
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            REPORT</B></FONT></TD></TR>
        <TR>
          <TD width=3D"33%" height=3D5></TD>
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        <TR>
          <TD class=3Dother width=3D"100%" colSpan=3D3><B>Year </B>: =
2009&nbsp;=20
            |&nbsp; <B>Volume</B> : 57&nbsp; |&nbsp; <B>Issue</B> : =
3&nbsp;=20
            |&nbsp; <B>Page</B> : 247-251</TD></TR></TBODY></TABLE>
      <P><FONT class=3DsTitle>A pragmatic clinicopathobiological =
grouping/staging=20
      system for gliomas: Proposal of the Indian TNM subcommittee on =
brain=20
      tumors</FONT><BR><BR><FONT class=3DarticleAuthor>Tejpal =
Gupta<SUP>1</SUP>,=20
      Rajiv Sarin<SUP>1</SUP>, Rakesh Jalali<SUP>1</SUP>, Suash=20
      Sharma<SUP>2</SUP>, Purna Kurkure<SUP>3</SUP>, Atul=20
      Goel<SUP>4</SUP></FONT><BR><FONT=20
      class=3DAuthorAff><SUP>1</SUP>&nbsp;Department of Radiation =
Oncology,=20
      ACTREC/TMH, Mumbai, India<BR><SUP>2</SUP>&nbsp;Department of =
Pathology,=20
      TMH, Tata Memorial Centre, Mumbai, =
India<BR><SUP>3</SUP>&nbsp;Department=20
      of Pediatric Oncology, TMH, Tata Memorial Centre, Mumbai,=20
      India<BR><SUP>4</SUP>&nbsp;Department of Neuro-Surgery, KEM =
Hospital,=20
      Mumbai, India<BR></FONT><BR>
      <TABLE class=3DPrePublication width=3D"40%" border=3D0>
        <TBODY>
        <TR>
          <TD>Date of Acceptance</TD>
          <TD>15-Feb-2009</TD></TR>
        <TR>
          <TD height=3D1>Date of Web Publication</TD>
          <TD>8-Jul-2009</TD></TR></TBODY></TABLE></P>
      <P><FONT class=3DCorrsAdd><B>Correspondence Address</B>:<BR>Rajiv=20
      Sarin<BR>Advanced Centre for Treatment Research and Education in =
Cancer=20
      Tata Memorial Centre, Kharghar, Navi Mumbai - 410210 =
<BR>India<BR><A=20
      =
href=3D"http://www.neurologyindia.com/login.asp?rd=3Darticle.asp?issn=3D0=
028-3886;year=3D2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=
=3DGupta"><IMG=20
      alt=3D"Login to access the Email id"=20
      src=3D"http://www.medknow.com/images/email.gif" border=3D0></A>
      <P><B>Source of Support:</B> None, <B>Conflict of Interest:</B>=20
      None</P><B>DOI:</B>&nbsp;10.4103/0028-3886.53261<BR><BR><A=20
      =
href=3D"http://www.copyright.com/ccc/openurl.do?sid=3DMedknow&amp;issn=3D=
0028-3886&amp;servicename=3Dall&amp;WT.mc_id=3DMedknow"=20
      target=3D_blank><IMG alt=3D"Get Permissions"=20
      src=3D"http://www.medknow.com/journals/images/gp.gif" =
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      <P></P>
      <TABLE cellSpacing=3D0 cellPadding=3D0 width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DinsideLine width=3D"100%" =
height=3D1></TD></TR></TBODY></TABLE>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub width=3D"85%" height=3D15>&nbsp;=BB<A=20
            name=3Dabstract></A>&nbsp;Abstract</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD width=3D"15%" height=3D15></TD></TR></TBODY></TABLE>
      <P class=3Dabst><B>Background:</B> There is no universally =
accepted staging=20
      system for primary brain tumors wherein prognostication is mainly =
based on=20
      complex composite indices<B> . Aim:</B> To develop a simple, =
pragmatic,=20
      and widely applicable grouping/staging system for gliomas, the =
most common=20
      primary brain tumor. <B>Materials and Methods:</B> An expert =
neurooncology=20
      panel with representation from radiation oncology, neurosurgery,=20
      pathology, radiology, and medical oncology had several rounds of=20
      discussion on issues pertinent to brain tumor staging. The trade =
off was=20
      between the accuracy of prognostic categorization and a pragmatic, =
widely=20
      applicable approach. <B>Results and Recommendations:</B> The=20
      Tumor-Node-Metastasis staging was considered irrelevant for =
gliomas that=20
      seldom metastasize to lymphatics or outside the neuraxis. Instead, =
a=20
      4-point staging/grouping system is proposed, using histological =
grade as=20
      the main prognostic variable and at least one stage migration =
based on=20
      other unfavorable features such as tumor location (brainstem); age =
(&lt;5=20
      years for all grades, &gt;50 years for high-grade, and &gt;40 =
years for=20
      low-grade gliomas); poor neurological performance status (NPS =
2-4);=20
      multicentricity and/or gliomatosis; and adverse biological =
parameters=20
      (proliferative index, angiogenesis markers, apoptotic index, =
cytogenetic=20
      abnormalities, and molecular markers). <B>Conclusion:</B> In =
absence of a=20
      grouping/staging system for primary brain tumors, =
prognostification is=20
      mostly based on complex composite indices. The proposed=20
      clinicopathobiological grouping/staging system for gliomas is a =
simple,=20
      pragmatic, and user-friendly tool with a potential to fulfill the=20
      objectives of staging classification.</P><BR>
      <P class=3Dkyds><B>Keywords:</B>&nbsp;Gliomas, prognosis, staging=20
      classification</P><BR>
      <TABLE class=3Dsitethis width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3Dother><B>How to cite this article:</B><BR>Gupta T, =
Sarin=20
            R, Jalali R, Sharma S, Kurkure P, Goel A. A pragmatic=20
            clinicopathobiological grouping/staging system for gliomas: =
Proposal=20
            of the Indian TNM subcommittee on brain tumors. Neurol India =

            2009;57:247-51</TD></TR></TBODY></TABLE><BR>
      <TABLE class=3Dsitethis width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3Dother><B>How to cite this URL:</B><BR>Gupta T, =
Sarin R,=20
            Jalali R, Sharma S, Kurkure P, Goel A. A pragmatic=20
            clinicopathobiological grouping/staging system for gliomas: =
Proposal=20
            of the Indian TNM subcommittee on brain tumors. Neurol India =
[serial=20
            online] 2009 [cited&nbsp;2009 Jul 31];57:247-51. Available=20
            from:&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/text.asp?2009/57/3/247/53261">http:=
//www.neurologyindia.com/text.asp?2009/57/3/247/53261</A></TD></TR></TBOD=
Y></TABLE><BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A=20
          name=3DIntroduction></A>&nbsp;=BB&nbsp;Introduction</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#top"><I=
MG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>Cancer =
staging is a=20
      fundamental activity in oncology. The International Union Against =
Cancer=20
      (UICC) and American Joint Committee on Cancer (AJCC) =
Tumor-Node-Metastasis=20
      (TNM) system<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref1"=20
      name=3Dft1>[1]</A></SUP> has been a benchmark for reporting the =
anatomic=20
      extent of disease and a major prognostic factor in predicting =
outcome for=20
      cancer patients for over 50 years.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref2"=20
      name=3Dft2>[2]</A></SUP> The major objectives of the TNM =
classification are=20
      to aid the clinician in planning treatment, give some indication =
of=20
      prognosis, assist in evaluating results of treatment, facilitate =
exchange=20
      of information between treatment centers, an d contribute to =
continuing=20
      investigations of cancer.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref2"=20
      name=3Dft2>[2]</A></SUP> Overall, the system is immensely useful =
and is a=20
      foundation of clinical decision-making and clinical practice =
guideline. It=20
      is indeed unfortunate that the current sixth edition TNM staging=20
      manual<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref1"=20
      name=3Dft1>[1]</A></SUP> does not contain any staging =
classification for=20
      primary brain tumors, which was omitted from fifth edition =
onwards.<SUP>=20
      <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref3"=20
      name=3Dft3>[3]</A></SUP> Although primary brain tumors account for =
&lt;2% of=20
      all neoplasms<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref4"=20
      name=3Dft4>[4]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref5"=20
      name=3Dft5>[5]</A> </SUP>they are associated with high morbidity =
and=20
      mortality. According to American Cancer Society<SUP> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref5"=20
      name=3Dft5>[5]</A></SUP> estimates, 20,500 new patients were =
expected to be=20
      diagnosed with primary malignant central nervous system (CNS) =
tumors with=20
      estimated deaths of 12,740 in the year 2007 in the United States =
of=20
      America. Primary brain tumors are the leading cause of death from=20
      childhood cancers and the second leading cause of cancer-related =
deaths in=20
      young adult males in the Western world.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref5"=20
      name=3Dft5>[5]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref6"=20
      name=3Dft6>[6]</A></SUP> In the absence of a recommended and =
widely accepted=20
      staging system, prognostication is variably based on =
clinicopathologic=20
      factors as considered relevant to the individual patient and open =
to the=20
      judgment of treating physician(s). There is an urgent need to =
develop a=20
      simple yet pragmatic staging/grouping system for primary brain =
tumors to=20
      guide clinical practice. <BR><BR><B>Aim<BR><BR></B>The aim was to =
develop=20
      a simple, pragmatic, and widely applicable grouping/staging system =
for=20
      primary brain tumors, to guide neurooncologists in clinical =
practice.=20
      <BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A=20
            name=3D"Materials and Methods"></A>&nbsp;=BB&nbsp;Materials =
and=20
          Methods</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#top"><I=
MG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>The TNM =
classification has=20
      evolved over the years, mainly to improve prognostic ability and =
to keep=20
      pace with the demands of clinical practice. Changes to the TNM=20
      classification were previously derived from a decision-making =
process=20
      based on expert opinions from several national TNM committees =
based on=20
      clinical relevance, evidence of improved prognostic ability, and=20
      acceptance by member organizations.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref2"=20
      name=3Dft2>[2]</A></SUP> A Brain Tumor Subcommittee was formed =
under the=20
      aegis of the Indian National TNM. The subcommittee constituted an =
expert=20
      panel comprising of radiation oncologists, neurosurgeons, =
pathologists,=20
      radiologists, and medical oncologists actively engaged in =
neurooncology=20
      practice. The panel deliberated and discussed issues pertinent to =
brain=20
      tumor staging through formal meetings and informally via E-mail:=20
      Exchanges. <BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A=20
            name=3D"Results and =
Recommendations"></A>&nbsp;=BB&nbsp;Results and=20
            Recommendations</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#top"><I=
MG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>The =
previous UICC and AJCC=20
      TNM staging system for brain tumors<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref7"=20
      name=3Dft7>[7]</A></SUP> has been deleted from the fifth and sixth =
editions=20
      of the staging manual, as it is redundant and not in widespread =
clinical=20
      use. A strict anatomic staging classification such as TNM may not =
be very=20
      relevant to brain tumors as they seldom involve regional =
lymphatics or=20
      metastasize outside the CNS. In addition they encompass a plethora =
of=20
      diverse histologies, and it may be more appropriate to classify =
them into=20
      broad histologic subcategories for staging purposes. Three broad=20
      histologic subcategories, viz. gliomas, embryonal CNS tumors, and =
primary=20
      CNS lymphomas were chosen for separate grouping/staging =
classification.=20
      This report gives an overview of staging/grouping of gliomas.=20
      <BR><BR><B>Gliomas<BR><BR></B>Gliomas are the commonest primary =
CNS=20
      neoplasms comprising over 40% of such tumors in adults.<SUP> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref5"=20
      name=3Dft5>[5]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref6"=20
      name=3Dft6>[6]</A></SUP> Histological grade as defined by the =
World Health=20
      Organization (WHO) system<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref8"=20
      name=3Dft8>[8]</A></SUP> is the most important prognostic factor =
that=20
      determines outcome in tumors of glial origin. Histological grading =
is an=20
      attempt to predict the biological behavior of a neoplasm. The WHO=20
      classification for CNS neoplasms, including gliomas, employs a =
grading=20
      scheme that is a 'malignancy scale' rather than a strict =
histological=20
      grading system. Grade I glioma refers to lesions having low =
proliferative=20
      potential with a possibility of cure following surgery alone. =
Grade II=20
      tumors are generally diffusely infiltrative in nature despite =
having low=20
      proliferative indices, with a marked potential for progression =
over time=20
      and subsequent transformation toward a higher grade. Only tumors =
with=20
      gross histological evidence of malignancy, such as nuclear atypia, =

      anaplasia, or mitosis, are categorized as grade III tumors. Tumors =
with=20
      microvascular proliferation and/or necrosis in addition to the =
aforesaid=20
      features of malignancy are categorized as grade IV tumors, and are =

      typically associated with a rapid evolution and fatal outcome. =
Gliomas can=20
      thus be subclassified into low-grade (WHO grades I and II) and =
high-grade=20
      (WHO grades III and IV) gliomas. The optimal management of =
low-grade=20
      gliomas, though somewhat debatable, is maximal safe resection with =
or=20
      without adjuvant radiotherapy. <SUP><A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref9"=20
      name=3Dft9>[9]</A></SUP> For high-grade gliomas, adjuvant =
radiotherapy with=20
      or without chemotherapy following maximal safe resection has been=20
      generally recommended.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref10" =

      name=3Dft10>[10]</A></SUP> Recent evidence supports the use of =
concurrent=20
      and adjuvant chemotherapy<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref11" =

      name=3Dft11>[11]</A></SUP> for grade IV gliomas, i.e. =
glioblastoma. In the=20
      absence of a widely accepted staging system, prognosis is based =
mostly on=20
      clinicopathological factors as considered relevant to the =
individual=20
      patient. However, it may be strongly influenced by the biases or=20
      prejudices of the treating physician and/or institutional practice =

      patterns and guidelines. <BR><BR><B>Prognostic =
indices<BR><BR></B>There=20
      have been several attempts to develop composite prognostic indices =
for=20
      both low-as well as high-grade gliomas. <BR><BR><B>Low-grade=20
      gliomas<BR><BR></B>Bauman and colleagues<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref12" =

      name=3Dft12>[12]</A></SUP> were the first to pool three large =
databases (401=20
      patients) to identify pretreatment factors that could predict =
overall=20
      survival in low-grade gliomas. Multivariate analysis showed age =
18-40=20
      years, seizures, Karnofsky performance status (KPS) &gt; 70, and =
absence=20
      of contrast enhancement as independent predictors of survival. =
Recursive=20
      partitioning analysis (RPA) yielded four distinct prognostic =
groups=20
      (I-IV), with statistically different median survivals. <BR><BR>The =

      European Organization for Research and Treatment of Cancer (EORTC) =

      spearheaded two large randomized controlled trials<SUP> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref13" =

      name=3Dft13>[13]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref14" =

      name=3Dft14>[14]</A> </SUP>that were designed to investigate the =
dose (EORTC=20
      22844) and timing of postoperative adjuvant radiotherapy (EORTC =
22845) in=20
      cerebral low-grade gliomas. Pignatti <I>et al.<SUP></I> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref15" =

      name=3Dft15>[15]</A></SUP> combined those two datasets to develop =
a=20
      prognostic score for low-grade gliomas. Multivariate analysis on =
the=20
      construction set of 322 patients showed age &#8805; 40 years, =
astrocytoma=20
      histology, tumor diameter &#8805; 6 cm, tumor crossing midline, =
and presence of=20
      neurologic deficits preoperatively as unfavorable prognostic =
factors for=20
      survival. Patients with one or two factors had low-risk disease =
whereas a=20
      higher score indicated high-risk disease. The validity of the =
model was=20
      confirmed in the validation set of 288 patients. In a more recent =
update=20
      of EORTC 22845, it was reconfirmed that early radiotherapy delays=20
      progression with no impact on overall survival.<SUP> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref16" =

      name=3Dft16>[16]</A></SUP> In the largest analysis of the patterns =
of care=20
      and long-term survival of patients with supratentorial low-grade =
gliomas,=20
      Claus<I> et al</I> .<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref17" =

      name=3Dft17>[17]</A></SUP> demonstrated increasing survival times =
(mean six=20
      years) over the years, with a quarter of patients surviving for =
decades.=20
      <BR><BR><B>High-grade gliomas<BR><BR></B>The Medical Research =
Council=20
      (MRC) brain tumor working party formulated a three-tiered =
prognostic=20
      index<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref18" =

      name=3Dft18>[18]</A></SUP> for high-grade gliomas using age, WHO =
performance=20
      status, extent of resection, and history of seizures as prognostic =

      factors. A cumulative score of &gt;25 was defined as poor =
prognosis=20
      (median survival 33 weeks), as compared to a score of &#8804;15 =
which was=20
      classified as favorable (median survival 80 weeks). <BR><BR>The =
Radiation=20
      Therapy Oncology Group (RTOG) used the RPA for classifying =
malignant=20
      gliomas into six prognostic classes<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref19" =

      name=3Dft19>[19]</A></SUP> using age, grade, KPS, mental status, =
symptom=20
      duration, extent of resection, neurodeficits, and total =
radiotherapy dose=20
      as prognostic factors based on three RTOG trials. Classes V and VI =
had a=20
      particularly poor outcome with a median survival of 8.9 and =
4.6months,=20
      respectively. A modified RPA classification<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref20" =

      name=3Dft20>[20]</A></SUP> based on 832 patients with GBM enrolled =
on=20
      prospective clinical trials uses age, KPS, site, and extent of =
resection=20
      as factors to subdivide the GBM population into four different =
prognostic=20
      groups - low-risk, low-moderate-risk, moderate-high-risk, and =
high-risk=20
      with a median survival of 132, 71, 63, and 37 weeks, respectively. =

      <BR><BR>However, neither the MRC index nor RPA was incorporated =
into=20
      routine clinical practice due to the complexities. A more recent =
attempt=20
      at developing a pragmatic system for prognosis<SUP> <A class=3Dref =

      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref21" =

      name=3Dft21>[21]</A></SUP> using age and neurological performance =
status=20
      (NPS) as the only prognostic variables discriminates well between =
the poor=20
      and favorable classes, but needs more robust validation in a =
larger=20
      cohort. <BR><BR><B>Proposed grouping system for =
gliomas<BR><BR></B>Based=20
      on data previously published in the indexed medical literature, =
certain=20
      characteristics are defined as unfavorable <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2009_57_3_247_53261_t1.jp=
g')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#">[Tabl=
e=20
      1]</A> for the proposed new classification. Since a strict =
anatomic system=20
      may not be very appropriate, a grouping/staging system is proposed =
<A=20
      class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2009_57_3_247_53261_t2.jp=
g')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#">[Tabl=
e=20
      2]</A> as is prevalent in some pediatric solid tumors.<SUP> <A =
class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref22" =

      name=3Dft22>[22]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref23" =

      name=3Dft23>[23]</A></SUP> <BR><BR>Group I: (expected excellent =
long-term=20
      survival)<BR><BR>
      <UL>
        <LI>Any grade I glioma (excepting brainstem =
gliomas)</LI></UL>Group II:=20
      (expected good long-term survival)<BR><BR>
      <UL>
        <LI>Grade I brainstem glioma (including unverified focal tectal =
plate=20
        gliomas)
        <LI>Grade II with no unfavorable characteristics (age, NPS,=20
        multicentricity, biology)</LI></UL>Group III: (expected fair =
long-term=20
      survival)<BR><BR>
      <UL>
        <LI>Grade II with any unfavorable characteristics (age, NPS,=20
        multicentricity, biology)
        <LI>Grade III with no unfavorable characteristics</LI></UL>Group =
IV:=20
      (expected poor long-term survival)<BR><BR>
      <UL>
        <LI>Any grade IV glioma
        <LI>Grade III with any unfavorable characteristics (age, NPS,=20
        multicentricity, biology)
        <LI>Any brainstem glioma except grade I or focal tectal plate=20
      glioma</LI></UL>Histological grade as defined by WHO system<SUP> =
<A=20
      class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref8"=20
      name=3Dft8>[8]</A> </SUP>remains the most important prognostic =
factors=20
      predicting outcome in gliomas, hence, it was kept as the primary =
variable=20
      <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2009_57_3_247_53261_t1.jp=
g')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#">[Tabl=
e=20
      1]</A>. Age, NPS, multicentricity, and biological parameters were=20
      classified as secondary variables. The cut-off age for defining =
adverse=20
      prognosis in low-grade gliomas was kept at 40 years based on the=20
      accumulated evidence on low-grade gliomas.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref12" =

      name=3Dft12>[12]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref13" =

      name=3Dft13>[13]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref14" =

      name=3Dft14>[14]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref15" =

      name=3Dft15>[15]</A></SUP> For high-grade gliomas, the cut-off was =
taken as=20
      50 years, as this has been widely used world over including the=20
      RPA-RTOG.<SUP><A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref19" =

      name=3Dft19>[19]</A></SUP> There has been a reluctance to use =
radiation=20
      therapy for brain tumors in very young children (&lt;3 years of =
age) due=20
      to risk of severe late neurocognitive sequelae.<SUP><A class=3Dref =

      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref24" =

      name=3Dft24>[24]</A>,<A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref25" =

      name=3Dft25>[25]</A></SUP> In recent times, several cooperative =
groups have=20
      raised this limit and prefer to avoid<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref26" =

      name=3Dft26>[26]</A></SUP> or at least defer<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref27" =

      name=3Dft27>[27]</A></SUP> radiotherapy till the age of 5 years. =
Hence age=20
      &lt;5 years was also considered an adverse feature due to =
difficulty in=20
      delivering optimal therapy to young children. NPS was considered =
instead=20
      of a general performance scale as it is a more reliable and robust =

      prognostic factor and correlates well with functional independence =
for=20
      brain tumor patients.<SUP> <A class=3Dref=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ref21" =

      name=3Dft21>[21]</A></SUP> Apart from conventional adverse =
histopathological=20
      characteristics which determine grade such as hypercellularity, =
nuclear=20
      pleomorphism, mitoses, anaplasia, microvascular/endothelial =
proliferation,=20
      and necrosis, certain other biological parameters not routinely =
used for=20
      grading but increasingly being recognized as reasonable adjuncts =
to=20
      maximize therapeutic benefit (MIB-1 index, angiogenesis markers, =
apoptotic=20
      index, cytogenetic abnormalities, and molecular markers) may be =
defined=20
      for refined classification depending on available infrastructure,=20
      expertise, and commitment. <BR><BR>Brainstem gliomas are a =
heterogeneous=20
      group of neoplasms with differing biological behavior and outcome. =
The=20
      most common subtype, diffuse intrinsic pontine glioma (&gt;75%), =
is=20
      generally not amenable to biopsy and carries a grave prognosis. =
The=20
      cervicomedullary and the dorsal exophytic subtypes (which can be =
safely=20
      biopsied, sometimes even resected) have better survival. Focal =
tectal=20
      plate gliomas, which are indolent and slow-growing have good =
long-term=20
      survival even without biopsy after cerebrospinal fluid diversion =
to=20
      ameliorate symptoms. Thus, all histologically unverified brainstem =
gliomas=20
      (except focal tectal plate gliomas) are classified in the group =
with the=20
      worst prognosis as they are likely to represent diffuse intrinsic =
pontine=20
      gliomas. <BR><BR>The panel also deliberated on the prognostic =
significance=20
      of several known patients, tumors, and treatment characteristics =
such as=20
      size of lesion, mass effect, midline shift, imaging features, =
seizures,=20
      extent of resection, and total radiation dose. It was a consensus =
decision=20
      to exclude them from the proposed grouping system. This does not =
reduce=20
      the significance of these well-known prognostic factors that need =
to be=20
      considered on a case-to-case basis, but was an attempt to keep the =
system=20
      simple, practical, and widely applicable. <BR><BR>Currently, an =
important=20
      limitation of the proposed system is lack of validation, which the =
authors=20
      propose to overcome by validating it in a large cohort of patients =

      enrolled on their institutional neurooncology database. The =
proposed=20
      system although most pertinent and relevant for pure astrocytomas =
could be=20
      reasonably extended to other gliomas such as oligodendrogliomas or =
mixed=20
      oligoastrocytomas, provided one appreciates their favorable =
inherent=20
      biology and consequent clinical behavior. It is hereby =
re-emphasized that=20
      this simple and pragmatic clinicopathobiological classification is =

      intended to guide neurooncology practice in the community setting =
and may=20
      not be entirely appropriate in the context of prospective clinical =
trials,=20
      for which more elaborate and robust indices already =
exist.<BR><BR><BR>
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub><A =
name=3DConclusion></A>&nbsp;=BB&nbsp;Conclusion</TD>
          <TD class=3Dinthis align=3Dright>&nbsp;</TD>
          <TD align=3Dright width=3D"15%"><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#top"><I=
MG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR><BR>In absence =
of a=20
      grouping/staging system for primary brain tumors, prognostication =
is=20
      mostly based on complex composite indices. The proposed =
grouping/staging=20
      system for gliomas is a simple, pragmatic, and user-friendly tool =
with a=20
      potential to fulfill the objectives of staging classification. =
This=20
      proposed system will require validation in different research and =
practice=20
      settings before it can be recommended for routine clinical=20
      practice.<BR><BR>&nbsp;
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub height=3D15><A=20
            name=3DReference></A>&nbsp;=BB&nbsp;References</TD>
          <TD class=3Dinthis align=3Dright height=3D15>&nbsp;</TD>
          <TD align=3Dright width=3D"15%" height=3D15><A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#top"><I=
MG=20
            alt=3DTop =
src=3D"http://www.neurologyindia.com/images/arrow_top.gif"=20
            border=3D0></A></TD></TR></TBODY></TABLE><BR>
      <TABLE class=3Dbody cellSpacing=3D0 cellPadding=3D0 width=3D"100%" =
border=3D0>
        <TBODY>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft1"=20
            name=3Dref1>1.</A></TD>
          <TD>Sobin LH, Wittekind CL, editors. TNM classification of =
malignant=20
            tumours. 6<SUP> th</SUP> ed. New York: John Wiley and Sons;=20
            2002.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft1"><I=
MG=20
            alt=3D"Back to cited text no. 1"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft2"=20
            name=3Dref2>2.</A></TD>
          <TD>Gospodarowicz MK, Miller D, Groome PA, Greene FL, Logan =
PA,=20
            Sobin&#8197;LH. The process for continuous improvement of =
the TNM=20
            classification. Cancer 2004;100:1-5.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft2"><I=
MG=20
            alt=3D"Back to cited text no. 2"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft3"=20
            name=3Dref3>3.</A></TD>
          <TD>Sobin LH, Wittekind CL, editors. TNM classification of =
malignant=20
            tumours. 5<SUP> th</SUP> ed. New York: John Wiley and Sons;=20
            1997.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft3"><I=
MG=20
            alt=3D"Back to cited text no. 3"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft4"=20
            name=3Dref4>4.</A></TD>
          <TD>Ferlay J, Bray F, Pisani P. GLOBOCAN 2002: Cancer =
Incidence,=20
            Mortality and Prevalence Worldwide, Version 2.0. IARC Cancer =
Base=20
            No. 5. Lyon: IARC Press; 2004.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft4"><I=
MG=20
            alt=3D"Back to cited text no. 4"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft5"=20
            name=3Dref5>5.</A></TD>
          <TD>American Cancer Society: Cancer facts and Figures 2007. =
Atlanta,=20
            American Cancer Society, 2007.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft5"><I=
MG=20
            alt=3D"Back to cited text no. 5"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft6"=20
            name=3Dref6>6.</A></TD>
          <TD>Central Brain Tumour registry of the United States =
(CBTRUS).=20
            Statistical Report 2005-2006. Primary brain tumours in the =
United=20
            States: 1998-2002. Hinsdale, IL.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft6"><I=
MG=20
            alt=3D"Back to cited text no. 6"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft7"=20
            name=3Dref7>7.</A></TD>
          <TD>Hermanek P, Sobin LH (editors): TNM classification of =
malignant=20
            tumours, 4<SUP> th</SUP> edition, Berlin, Springer-Verlag,=20
            1987.&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft7"><I=
MG=20
            alt=3D"Back to cited text no. 7"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft8"=20
            name=3Dref8>8.</A></TD>
          <TD>Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, =
Jouvet=20
            A, et al. The 2007 WHO classification of tumours of the =
central=20
            nervous system. Acta Neuropathol 2007;114:97-109. =
&nbsp;&nbsp;<A=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft8"><I=
MG=20
            alt=3D"Back to cited text no. 8"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft9"><I=
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IMG=20
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            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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IMG=20
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IMG=20
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            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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IMG=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft14"><=
IMG=20
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            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft15"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft15"><=
IMG=20
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            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft16"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft16"><=
IMG=20
            alt=3D"Back to cited text no. 16"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft17"=20
            name=3Dref17>17.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft17"><=
IMG=20
            alt=3D"Back to cited text no. 17"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft18"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft18"><=
IMG=20
            alt=3D"Back to cited text no. 18"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft19"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft19"><=
IMG=20
            alt=3D"Back to cited text no. 19"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft20"=20
            name=3Dref20>20.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft20"><=
IMG=20
            alt=3D"Back to cited text no. 20"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft21"=20
            name=3Dref21>21.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft21"><=
IMG=20
            alt=3D"Back to cited text no. 21"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft22"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft22"><=
IMG=20
            alt=3D"Back to cited text no. 22"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft23"=20
            name=3Dref23>23.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft23"><=
IMG=20
            alt=3D"Back to cited text no. 23"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
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          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft24"=20
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft24"><=
IMG=20
            alt=3D"Back to cited text no. 24"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft25"=20
            name=3Dref25>25.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft25"><=
IMG=20
            alt=3D"Back to cited text no. 25"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
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href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft26"=20
            name=3Dref26>26.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft26"><=
IMG=20
            alt=3D"Back to cited text no. 26"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR>
        <TR>
          <TD vAlign=3Dtop width=3D"5%"><A class=3Dref=20
            =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft27"=20
            name=3Dref27>27.</A></TD>
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2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#ft27"><=
IMG=20
            alt=3D"Back to cited text no. 27"=20
            src=3D"http://www.neurologyindia.com/images/ref_top.gif"=20
            =
border=3D0></A>&nbsp;&nbsp;&nbsp;&nbsp;</TD></TR></TBODY></TABLE><BR><BR>=
<BR>&nbsp;<BR>&nbsp;
      <TABLE class=3DleftNav cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD class=3DpageSub>&nbsp;&nbsp;&nbsp;&nbsp;<A=20
        name=3Databs></A>Tables</TD></TR></TBODY></TABLE><BR>&nbsp; <A =
class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2009_57_3_247_53261_t1.jp=
g')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#">[Tabl=
e=20
      1]</A>, <A class=3Dref=20
      =
onmouseover=3D"omovimg('viewimaget.asp?img=3Dni_2009_57_3_247_53261_t2.jp=
g')"=20
      =
href=3D"http://www.neurologyindia.com/article.asp?issn=3D0028-3886;year=3D=
2009;volume=3D57;issue=3D3;spage=3D247;epage=3D251;aulast=3DGupta#">[Tabl=
e=20
      2]</A>=20
      <TABLE cellSpacing=3D0 cellPadding=3D0 width=3D"100%" border=3D0>
        <TBODY>
        <TR>
          <TD width=3D"100%">
            <P align=3Dleft><BR>
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link[6]+=3D'<td width=3D"44%" class=3D"topBand1Sel" align=3D"right"><a =
class=3D"topmenu" href=3D'+SITE_URL +'whatsnew.asp>What\'s =
New</a>&nbsp;&nbsp;|&nbsp;<a class=3D"topmenu" href=3D'+SITE_URL =
+'alerts.asp>Table of Contents Alerts</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a =
class=3D"topmenu" href=3D'+SITE_URL =
+'links.asp>Links</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a class=3D"topmenu" =
href=3D'+SITE_URL =
+'sitestatistics.asp>Hits</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a =
class=3D"topmenu" href=3D'+SITE_URL =
+'searchmeeting.asp>Conferences</a>&nbsp;&nbsp;</td>';
link[6]+=3D'<td width=3D"10%">&nbsp;</td></tr></table>';

link[7]=3D'<table border=3D0 cellpadding=3D"0" cellspacing=3D"0" =
class=3D"topBand2" width=3D"100%"><tr><td width=3D"51%" =
height=3D"20px">&nbsp;</td>';
link[7]+=3D'<td width=3D"35%" align=3D"right" class=3D"topBand1Sel" =
height=3D"20px"><a class=3D"topmenu" href=3D'+SITE_URL =
+'addresses.asp>Addresses</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a =
class=3D"topmenu" href=3D'+SITE_URL +'advertise.asp>Advertise with =
us</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a class=3D"topmenu" href=3D'+SITE_URL =
+'feedback.asp>Feedback</a>&nbsp;&nbsp;|&nbsp;&nbsp;<a class=3D"topmenu" =
href=3D'+SITE_URL +'joinus.asp>Apply as Referee </a>&nbsp;&nbsp;</td>';
link[7]+=3D'<td width=3D"2%">&nbsp;</td></tr></table>';



function lib_bwcheck(){ //Browsercheck (needed)
	this.ver=3Dnavigator.appVersion
	this.agent=3Dnavigator.userAgent
	this.dom=3Ddocument.getElementById?1:0
	this.opera5=3Dthis.agent.indexOf("Opera 5")>-1
	this.ie5=3D(this.ver.indexOf("MSIE 5")>-1 && this.dom && =
!this.opera5)?1:0;=20
	this.ie6=3D(this.ver.indexOf("MSIE 6")>-1 && this.dom && =
!this.opera5)?1:0;
	this.ie4=3D(document.all && !this.dom && !this.opera5)?1:0;
	this.ie=3Dthis.ie4||this.ie5||this.ie6
	this.mac=3Dthis.agent.indexOf("Mac")>-1
	this.ns6=3D(this.dom && parseInt(this.ver) >=3D 5) ?1:0;=20
	this.ns4=3D(document.layers && !this.dom)?1:0;
	this.bw=3D(this.ie6 || this.ie5 || this.ie4 || this.ns4 || this.ns6 || =
this.opera5)
	return this;
}




function showHideLayer(obj,visible)
{							=09
	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	this.css.visibility =3D visible;
	this.css.top=3D'100px';
	this.css.left=3D'12px';
	if (bw.ie5 ||bw.ie4 || bw.ie6)
		this.css.width=3D'100%';=09
	else
		this.css.width=3D'98%';=09

	this.css.position=3D"absolute";

}


function writeSubmenu(obj,item)
{							=09
   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	thecontent=3D(item=3D=3D-1)? "" : link[item]
	this.wref.innerHTML=3Dthecontent;

}


function navleftMouseOver(src)
{=20

	src.className=3D"leftnavcellover";
}=20



function navleftMouseOut(src)
{=20
	src.className=3D"";
}

function navtabMouseOver(src)
{=20
	src.className=3D"topBand1MO";
}=20



function navtabMouseOut(src)
{=20
	src.className=3D"topBand1";
}


function navMouseOver(src,item)
{=20
	if (item !=3D default_menu_item)
	src.className=3D"topBand1MO";=09

}=20



function navMouseOut(src,lyr)
{=20
	if (lyr!=3Ddefault_menu_item)
	src.className=3D"topBand1";=09
}

function onlpgld(item)
{
	default_menu_item=3Ditem;=09
	resetTDs(item);
	writeSubmenu("submenu",item);
	showHideLayer("submenu","visible");
}


function navMouseBotOut(src)
{
	src.className=3D"footer";
}


function navMouseBotOver(src)
{
	src.className=3D"pageSub";
}


function menu(src,item)
{=20

=09
	default_menu_item =3D item;
	writeSubmenu("submenu",item);
	showHideLayer("submenu","visible");=09
	resetTDs(item);

}=20

function resetTDs(item)
{
	var ob;
	for(x=3D0;x<8;x++)
	{
	obj=3D"m" + x;
 	ob=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	ob.className=3D"topBand1";
	if (x =3D=3D item)
		{
		ob.className=3D"topBand1Sel";
		}=09
	}
}


function writehDetail(obj,nm,cate,sing,dble,chkout,webadd)
	{			=09

   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09

	var det;
	if (sing=3D=3D0){
		sing=3D"N.A";}
	else{
		sing=3D sing + " INR";}

	if (dble=3D=3D"0")
		dble =3D"N.A"
	else
		dble=3D dble+ " INR";

	if (webadd !=3D '')
	{
		=
det=3D'Hotel&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;:=
 <b>'+nm + '</b><br>Category&nbsp;&nbsp;&nbsp;&nbsp;:<b> '+ cate =
+'</b><br>Singlebed&nbsp;&nbsp;&nbsp;:<b> '+ sing =
+'</b><br>Doublebed&nbsp;&nbsp;:<b> '+ dble + =
'</b><br>Checkout&nbsp;&nbsp;&nbsp;&nbsp;: <b>' + chkout + =
'</b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a target=3D"_blank" =
href=3D"'+webadd+'">More Details >></a>';
	}
	else
	{
		=
det=3D'Hotel&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;:=
 <b>'+nm + '</b><br>Category&nbsp;&nbsp;&nbsp;&nbsp;:<b> '+ cate =
+'</b><br>Singlebed&nbsp;&nbsp;&nbsp;:<b> '+ sing =
+'</b><br>Doublebed&nbsp;&nbsp;:<b> '+ dble + =
'</b><br>Checkout&nbsp;&nbsp;&nbsp;&nbsp;: <b>' + chkout + '</b>';
	}=09

	this.wref.innerHTML=3Ddet;
}


function writetoObj(obj,curr, valu)
	{=09


   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	this.wref.innerHTML=3D"<b>"+ curr+ valu + "</b>";
}
function openLogo(ClientID)
{
var attributes =3D 'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D550,height=3D600,left=3D=
0,top=3D0';
sealWin=3Dwindow.open('http://www.ccavenue.com/verifySeal.jsp?ClientID=3D=
'+ClientID ,'win',attributes);=20
self.name =3D 'mainWin';=20
}
function openWin(pg)
{

	if (pg.indexOf('special') >=3D 0 )
		{
		var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D800,height=3D600,left=3D=
0,top=3D0';
		}
	else
		{
		var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D600,height=3D400,left=3D=
0,top=3D0';
		}

	sealWin=3Dwindow.open(pg ,'',attributes);=20
	self.name =3D pg;=20
}

function chkgcform(frm)
{
	if (document.gc_form.gc_login.value=3D=3D'')
	{
		alert("Please enter your Gold Con username");
		return false;
	}
	if (document.gc_form.gc_pswd.value=3D=3D'')
	{
		alert("Please enter your Gold Con password");
		return false;
	}
	return true;
}
function writetCV(obj,cv,photo)
	{=09


   	this.evnt=3Dbw.dom? =
document.getElementById(obj):bw.ie4?document.all[obj]:bw.ns4?document.lay=
ers[obj]:0;
	if(!this.evnt) return false;
	this.css=3Dbw.dom||bw.ie4?this.evnt.style:bw.ns4?this.evnt:0;=09
   	this.wref=3Dbw.dom||bw.ie4?this.evnt:bw.ns4?this.css.document:0;=09
	this.wref.innerHTML=3D"<img src=3D'gc_images/" + photo + "'><br><br>" + =
cv;
}

function valfld(field)
{

	var valid =3D "0123456789"; // these are allowed values
	var ok =3D "yes";
	var temp;
	if (field.value.length =3D=3D 0 )
	{
		//alert("Invalid entry! please enter number");
		field.value =3D ""
		field.focus();
		field.select();
		return false;=09
	}
	for (var i=3D0; i<field.value.length; i++)
	{
		temp =3D "" + field.value.substring(i, i+1);
		if (valid.indexOf(temp) =3D=3D "-1")=20
		ok =3D "no";
	}
	if (ok =3D=3D "no")=20
	{
		alert("Invalid entry! Only numbers are allowed!");
		field.value =3D ""
		field.focus();
		field.select();

		return false;
	}
	else
		return true;
	}


function chkvldemail(email_address)
   {
         //Assumes that valid email addresses consist of =
user_name@domain.tld
         at =3D email_address.indexOf('@');
         dot =3D email_address.indexOf('.');
        =20
         if(at =3D=3D -1 ||=20
            dot =3D=3D -1 ||        =20
            dot =3D=3D 0 ||=20
            dot =3D=3D email_address.length - 1)
		{alert("Please enter valid email address.");
            return(false);
		}
           =20
         user_name =3D email_address.substr(0, at);
         domain_name =3D email_address.substr(at + 1, =
email_address.length);                 =20

         if(Validate_String(user_name) =3D=3D=3D false || =
Validate_String(domain_name) =3D=3D=3D false)
		{=09
			alert("Please enter valid email address.");
	            return(false);=20
                }
         else
		 return(true);
}

function Validate_String(string, return_invalid_chars)
         {
         valid_chars =3D =
'1234567890-_.^~abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ';
         invalid_chars =3D '';
        =20
         if(string =3D=3D null || string =3D=3D '')
            return(true);
        =20
         //For every character on the string.  =20
         for(index =3D 0; index < string.length; index++)
            {
            charx =3D string.substr(index, 1);                       =20
           =20
            //Is it a valid character?
            if(valid_chars.indexOf(charx) =3D=3D -1)
              {
              //If not, is it already on the list of invalid characters?
              if(invalid_chars.indexOf(charx) =3D=3D -1)
                {
                //If it's not, add it.
                if(invalid_chars =3D=3D '')
                   invalid_chars +=3D charx;
                else
                   invalid_chars +=3D ', ' + charx;
                }
              }
            }                    =20
           =20
         //If the string does not contain invalid characters, the =
function will return true.
         //If it does, it will either return false or a list of the =
invalid characters used
         //in the string, depending on the value of the second =
parameter.
         if(return_invalid_chars =3D=3D true && invalid_chars !=3D '')
           {
           last_comma =3D invalid_chars.lastIndexOf(',');
          =20
           if(last_comma !=3D -1)
              invalid_chars =3D invalid_chars.substr(0, $last_comma) +=20
              ' and ' + invalid_chars.substr(last_comma + 1, =
invalid_chars.length);
                     =20
           return(invalid_chars);
           }
         else
           return(invalid_chars =3D=3D '');=20
         }

function trimstr(par)
{

while (par.charAt(0)=3D=3D" "){
par=3Dpar.replace(" ","")
}
i=3Dpar.length-1
while(par.charAt(i)=3D=3D" "){
par=3Dpar.slice(0,i)
i=3Di-1
}
return par
}

// var xyz =3D createBar(
// total_width,
// total_height,
// background_color,
// border_width,
// border_color,
// block_color,
// scroll_speed,
// block_count,
// scroll_count,
// action_to_perform_after_scrolled_n_times
// )

var w3c=3D(document.getElementById)?true:false;
var ie=3D(document.all)?true:false;
var N=3D-1;
var back_color=3D'white';
var bar_color=3D'green';
function =
createBar(w,h,bgc,brdW,brdC,blkC,speed,blocks,count,action,flag){
if(ie||w3c){

	bgc=3Dback_color;
	blkC=3Dbar_color;

if (flag!=3D''){
	h=3D13;
	}
h=3D10
var t=3D'<div id=3D"_xpbar'+(++N)+'" style=3D"visibility:visible; =
position:relative; overflow:hidden; width:'+w+'px; height:'+h+'px; =
background-color:'+bgc+'; border-color:'+brdC+'; =
border-width:'+brdW+'px; border-style:solid; font-size:1px;">';
t+=3D'<span id=3D"blocks'+N+'" style=3D"left:-'+(h*2+1)+'px; =
position:absolute; font-size:1px">';
for(i=3D0;i<blocks;i++){
t+=3D'<span style=3D"background-color:'+blkC+'; left:-'+((h*i)+i)+'px; =
font-size:1px; position:absolute; width:'+h+'px; height:'+h+'px; '
t+=3D(ie)?'filter:alpha(opacity=3D'+(100-i*(100/blocks))+')':'-Moz-opacit=
y:'+((100-i*(100/blocks))/100);
t+=3D'"></span>';
}
t+=3D'</span></div>';
document.write(t);
var =
bA=3D(ie)?document.all['blocks'+N]:document.getElementById('blocks'+N);
bA.bar=3D(ie)?document.all['_xpbar'+N]:document.getElementById('_xpbar'+N=
);
bA.blocks=3Dblocks;
bA.N=3DN;
bA.w=3Dw;
bA.h=3Dh;
bA.speed=3Dspeed;
bA.ctr=3D0;
bA.count=3Dcount;
bA.action=3Daction;
bA.togglePause=3DtogglePause;
bA.showBar=3Dfunction(){
this.bar.style.visibility=3D"visible";
}
bA.hideBar=3Dfunction(){
this.bar.style.visibility=3D"hidden";
}
bA.tid=3DsetInterval('startBar('+N+')',speed);
return bA;
}}

function startBar(bn){
var =
t=3D(ie)?document.all['blocks'+bn]:document.getElementById('blocks'+bn);
if(parseInt(t.style.left)+t.h+1-(t.blocks*t.h+t.blocks)>t.w){
t.style.left=3D-(t.h*2+1)+'px';
t.ctr++;
if(t.ctr>=3Dt.count){
eval(t.action);
t.ctr=3D0;
}}else t.style.left=3D(parseInt(t.style.left)+t.h+1)+'px';
}

function togglePause(){
if(this.tid=3D=3D0){
this.tid=3DsetInterval('startBar('+this.N+')',this.speed);
}else{
clearInterval(this.tid);
this.tid=3D0;
}}

function togglePause(){
if(this.tid=3D=3D0){
this.tid=3DsetInterval('startBar('+this.N+')',this.speed);
}else{
clearInterval(this.tid);
this.tid=3D0;
}}
function showpp(el_id)

{

	if (document.getElementById(el_id).style.display=3D=3D"")
	{
	document.getElementById(el_id).style.display=3D"none";
	}
	else
	{
	document.getElementById(el_id).style.display=3D""
	var attributes =3D =
'toolbar=3D0,location=3D0,directories=3D0,status=3D0, =
menubar=3D0,scrollbars=3D1,resizable=3D1,width=3D1,height=3D1,left=3D0,to=
p=3D0';


	=
sealWin=3Dwindow.open('http://www.jpgmonline.com/vans.asp','',attributes)=
;=20
	}=09
}


var ns =3D (navigator.appName.indexOf("Netscape") !=3D -1);
var d =3D document;
var px =3D document.layers ? "" : "px";

function JSFX_FloatDiv(id, sx, sy)
{
	var =
el=3Ddocument.getElementById?document.getElementById(id):document.all?doc=
ument.all[id]:document.layers[id];
	window[id + "_obj"] =3D el;
	if(document.layers)el.style=3Del;
	el.cx =3D el.sx =3D sx;el.cy =3D el.sy =3D sy;
	el.sP=3Dfunction(x,y){this.style.left=3Dx+px;this.style.top=3Dy+px;};
	el.flt=3Dfunction()
	{
		var pX, pY;
		pX =3D (this.sx >=3D 0) ? 0 : ns ? innerWidth :=20
		document.documentElement && document.documentElement.clientWidth ?=20
		document.documentElement.clientWidth : document.body.clientWidth;
		pY =3D ns ? pageYOffset : document.documentElement && =
document.documentElement.scrollTop ?=20
		document.documentElement.scrollTop : document.body.scrollTop;
		if(this.sy<0)=20
		pY +=3D ns ? innerHeight : document.documentElement && =
document.documentElement.clientHeight ?=20
		document.documentElement.clientHeight : document.body.clientHeight;
		this.cx +=3D (pX + this.sx - this.cx)/8;this.cy +=3D (pY + this.sy - =
this.cy)/8;
		this.sP(this.cx, this.cy);
		setTimeout(this.id + "_obj.flt()", 40);
	}
	return el;
}

document.write('<script type=3D"text/javascript" =
src=3D"http://ajax.googleapis.com/ajax/libs/jquery/1.3.2/jquery.min.js"><=
\/script>')
document.write('<script type=3D"text/javascript" =
src=3D"http://www.medknow.com/if/iflogo.js"><\/script>')

document.write('<script type=3D"text/javascript" =
src=3D"http://www.medknow.com/js/_dirj.js"><\/script>')
------=_NextPart_000_0000_01CA1206.F5B230C0
Content-Type: application/octet-stream
Content-Transfer-Encoding: 7bit
Content-Location: http://www.medknow.com/js/_getUACode.js

var j_ur = new Array("www.afrjpaedsurg.org",
"www.annals.in",
"www.annalsofian.org",
"www.annalspc.com",
"www.thoracicmedicine.org",
"www.atmph.org",
"www.asiapharmaceutics.info",
"www.ajts.org",
"www.conservationandsociety.org",
"www.cytojournal.com",
"www.hepatitisbannual.org",
"www.je.ietejournals.org",
"www.jr.ietejournals.org",
"www.tr.ietejournals.org",
"",
"www.indianjcancer.com",
"www.ijcm.org.in",
"www.ijccm.org",
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"www.ijdvl.com",
"www.indianjgastro.com",
"www.ijhg.com",
"www.ijmm.org",
"www.indianjmedsci.org",
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"www.ijnm.in",
"www.ijoem.com",
"www.ijo.in",
"www.ijoonline.com",
"www.ijohns.com",
"www.jpalliativecare.com",
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"www.ijp-online.com",
"www.ijps.org",
"www.indianjpsychiatry.org",
"www.ijpm.info",
"www.ijri.org",
"www.ijstd.org",
"www.indianjsurg.com",
"www.indianjurol.com",
"www.ijaronline.com",
"www.ijddc.com",
"www.greenpharmacy.info",
"www.internationalshoulderjournal.org",
"www.ijtrichology.com",
"www.ijoy.org.in",
"www.cancerjournal.net",
"www.carcinogenesis.com",
"www.jcd.org.in",
"www.jcvjs.com",
"www.jcasonline.com",
"www.jcytol.org",
"www.jdionline.org",
"www.jeed.in",
"www.onlinejets.org",
"",
"www.jgid.org",
"www.gynecendoscopy.org",
"www.jhrsonline.org",
"www.jiaomr.org",
"www.jiaps.com",
"www.jprosthodont.com",
"www.jisppd.com",
"www.jisponline.com",
"www.jlponline.org",
"www.jmp.org.in",
"www.journalofmas.com",
"www.jomfp.in",
"www.jpd.org.in",
"www.pediatricneurosciences.com",
"www.jpgmonline.com",
"",
"www.lungindia.com",
"www.mlcd.in",
"www.msmonographs.org",
"www.neurologyindia.com",
"www.noiseandhealth.org",
"www.ojoonline.org",
"www.ipapharma.org",
"www.pulmonarycirculation.org",
"www.pvrireview.org",
"www.saudijgastro.com",
"www.sjkdt.org",
"www.urologyannals.com",
"www.ysjournal.com",
"www.jfoonline.org",
"www.meajo.org",
"www.ijmpo.org")

var j_UA = new Array ("UA-4163080-13",
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function getUACode()
{
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	j_dom=escape(document.domain);
	j_dom = j_dom.toLowerCase();
	j_dom= j_dom.replace(/www./,'');

	j_dom = 'www.'+j_dom;

	for (i=0;i<j_ur.length ;i++ )
	{
		if(j_ur[i]==j_dom)
		{
			return j_UA[i];
			break;
		}
	}
}

function getAdSenseCode()
{
	var j_domn ;
	j_domn=escape(document.domain);
	j_domn = j_domn.toLowerCase();
	j_domn= j_domn.replace(/www./,'');

	j_domn = 'www.'+j_domn;
	
	for (i=0;i<j_ur.length ;i++ )
	{
		if(j_ur[i]==j_domn)
		{
			return j_Adsense[i];
			break;
		}
	}
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