Profile of eyelid tumors at tertiary care institute in Karnataka: a 5-years survey.
Wide varieties of lesions affecting the eyelid are encountered within routine ophthalmology practice. These lesions are numerous due to the unique anatomical features of the eyelid as the whole skin structures, appendages, muscle, modified glands, and conjunctival mucous membrane are represented in the eyelid.  Benign tumors reported in an Indian study by Abdi et al include vascular tumors, neural tumors, dermoid cysts, squamous cell papilloma and naevi.  Several studies have found different incidences of each of these lesions. [2-6,9-16]
Among the malignant category, basal cell carcinoma(BCC) has been shown to have the highest incidence among the malignant tumors of the eye lids followed by sebaceous gland carcinoma (SGC), lymphoma, squamous cell carcinoma(SCC), and malignant melanoma.  However the frequency of SCG is higher in Asian countries. [2,8,17-21]
The present retrospective study evaluated the clinic pathological profile of different eyelid tumors in a tertiary care hospital.
MATERIALS AND METHODS: A retrospective case analysis was conducted at the department of Ophthalmology, Mysore Medical College and Research Institute, Mysore, Karnataka, South India. Hospital records of the patients who had undergone treatment for various eye lid lesions from the 15th June 2009 to 15th June 2014, over a 5 year period were reviewed. A total of 235 cases were evaluated for during this period.
The various clinical parameters that were assessed included age, gender, occupation, the length of time between the onset of the disease and referral, the symptoms at each visit, visual acuity, history of trauma and history of tumors in other parts of the body. The affected eye and the eye lid involved were examined, the location, size, physical appearance of the lesion were also noted.
Also, limitation of ocular motility, fundoscopic findings, the anterior and posterior segments of the eye was examined by slit lamp and indirect ophthalmoscope respectively. Visual acuity was recorded using the Snellen's Chart. Type of surgical procedure and technique for repairing the eyelid, treatment results, follow-up examinations and the recurrence of the tumor were recorded. Histopathological correlation was also done in all the cases.
All benign and malignant tumors (including recurrence) were managed by surgical excision of the lesion and lid reconstruction where ever required. All cases that were suspected to be malignant were managed by wide surgical excision of the lesion large enough to obtain tumor-free margins and confirmed by histopathological examination.
RESULTS: Out of 235 cases, 216(91.9 %) of the eyelid lesions were benign tumors and 19(8.1%) were malignant. The age of the patients ranged from 3 to 85 years.
Most benign tumors were diagnosed in patients under the age of 60 years. There were 138 females (58.71%) and 97 males (41.3 %), benign tumors were more prevalent among females (n=130, 60%) than in males (n=86, 40%), male to female ratio was 1:1.5. Benign tumors involved the upper eyelid (n=131, 60.6%) more commonly than lower lid (n=85, 39.4%).Involvement of the upper eyelid was more often noted in some pathologic lesions like epidermal cyst, papilloma, and dermoid cysts. Nevi were more common in the lower eyelid.
The most prevalent type of the benign eyelid masses were epidermal cyst (30.5%), nevi (17.5%), dermoidcyst (13.8%), followed by papillomas (6.5%). Other benign lesions included capillary hemangioma, seborrhic keratosis, benign fibrous histiocytoma, verruca, eccrinespiradenoma, pilomatricoma, apocrine hydrocystoma, trichoepithelioma, sebaceoushorn, neuroma, neurfibroma, lipoma and fibroma. [Table 1].
Epidermal cysts represented 30.5% (66cases) of all benign lesions. The age group affected was between second to sixth decade, accounting for 55 cases. A preference for upper lid (74.24%) and the right eyelid (66.6%), but no gender preference was seen. Nevi represented 17.5% of all benign lesions, showed a female predominance (89%), more commonly found in the3rd to 4th decade and in the lower lid.
Dermoid cysts accounted for 13.8% of benign tumors. Involvement of the upper lid was noted in all these cases; left eye to right eye involvement was 5:1 and was found in the younger age group.
No gender predilection was noted. Papilloma accounted for 6.5% of cases, demonstrated a greater involvement of upper eyelid, but no gender or eye preference was seen.
In the present study, 19 cases (8.1%) were diagnosed as malignant eyelid tumors, of which six were SGC (31.6%), five were BCC (26.3%), four were SCC (21%), two were malignant melanoma (10.5%) and one each of lymphoma (5.3%) and Merkel cell carcinoma (MCC) (5.3%).The mean age of the patients under the malignant category was 62.2years.The male to female ratio was 1: 0.7. Regarding the malignant group, the lower lid was involved more (n=14, 74%) than the upper lid (n=5, 26%). [Table2] The most common location of malignant tumors was lower lid (74%).
The lower lid was also the most common location of tumor for all histological subtypes except SGC where 83.3% of cases involved the upper lid. The most common presenting complaint was mass with ulceration across all histological types. 4 patients of BCC (21%), 3 patients of SGC (16%) and 3 patients of SCC (16%) presented with mass and overlying ulceration. Mass alone was the presenting complaint in 1 patients of BCC, 3 patients of SGC and 1 patient of SCC. Other associated complaints included redness, discharge from eye, pain and ptosis. Two patients of SGC had history of recurrent chalazion.
The mean length of time between the onset of the disease and referral of the patient for benign and malignant tumors was 96 [+ or -] 24.0 and 18 [+ or -] 12.0 months respectively. Among the malignant tumors, this time was 20 months for BCC, 10 months for SGC, 8 months for SCC, 7 months for malignant melanoma, 4months for MCC and 2 months for lymphoma.
The average follow-up of patients with benign and malignant tumors was 60 months. One patient who was diagnosed to have BCC, had recurrence in left lower lid after 10 months of surgery. We had one case MCC with lymph node enlargement. No distant metastasis in our series.
DISCUSSION: From the retrospective data collected clinic pathological profile of 235 cases with eyelid tumors were reviewed in our hospital. The prevalence of different types of eyelid tumors is influenced by Geographical region, latitude, people protecting themselves from sunlight and Ultraviolet exposure, ethnicity and Genetic factors, 
In our study, 216 cases (91.9%) were benign eyelid tumours, nearly similar to that reported by Xu et al from Beijing (86.2% benign involving 2638 patients),  Deprez et al (84% benign from study on 5504 cases),  Paul S et al (855 cases, 75.9% were benign)  and Obata H et al (73% of 131 cases).  However studies by Abdi et al  from India and Bagheri A et al  from Tehran have reported only 58.9% (n= 207 cases) and 45.5% (n=182 cases)respectively, showing comparatively lesser incidence of benign lesions. In the general population, benign lesions largely constitute most frequent type of eyelid tumors out numbering the malignant category. [2,3,5,8,11] [Graph 1].
In our series the most common benign lesions were epidermal cyst (30.5%), nevi (17.5%), dermoid cyst (13.8%) and papilloma (6.5%). However Abdi et al reported vascular tumors (21.3%), neural tumors (18.0%), dermoid cysts (16.4%), squamous cell papilloma (13.1%) and naevi (12.3%) as the common benign lesions.  Different studies reported various frequencies of benign tumours some of which are similar to our study. Hsu and Lin et al series reported epidermal cysts (23.1%)  to be the most common lesion and Kersten et al reported it as the 2nd most common lesion in their cases series(22.2%). 
Four separate studies from Tehran, China, Southern Taiwan and South Korea have reported that the most frequent benign tumors were nevus, papilloma, and cysts. [2,7,8,16] Kersten et al  from The United States and Ni et al from China  reported papilloma (43.9% and 27.9%, respectively) to be the most common lesion, Chi et al and Beak et al (South Korea57.1%),  A Bagheri et al(Tehran 35%), Obata et al (Japan21.9%) and Mary Ho et al(Hong Kong 27%) found nevus [2,11,12] and YH. ALFaky et al (Saubi Arabia) documented sweat gland hidrocystoma (29.3%) as the most common benign eyelid lesion.  [Table 3]
Studies from by Pornpanich et al,  Chang C H et al  and A Bagheri et al  reported 51%, 46%, 57% involvement of upper eyelid in the benign category respectively and more prevalence in females. 
In contrast, a Chinese study, reported that the lower eyelid was involved slightly more frequently than upper eyelid. 
Histopathological studies confirmed the clinical diagnosis in 94.44% (204/216) specimens of benign lesions. However discordance between the clinical and histopathological diagnosis was noted in 5.5% (12/216) of the benign lesions. None of the clinically diagnosed benign tumors were proved to be malignant or premalignant lesions, however high index of suspicious and relatively low incidence of malignant lesions can explain such a difference. Nevertheless, twelve benign eyelid lesions (5.5%) were misdiagnosed clinically and proved by histopathology study to be another entity of benign lesions which is higher than Kersten et (2.3%), YH.AL-Faky et al(4.1%) and less than Ozdalet al(6.4%). [2,14]
Malignant tumours of the eyelid, which are of different histological types are encountered in Ophthalmic practice. These malignant tumors present differently, their progression varies and response to surgery differs.  The three most common malignant tumors in our study were SGC (31.5%), BCC (26.3%), and SCC (21%) which was similar to an Indian study by Sihota et al sebaceous adenocarcinoma (32.6%), BCC (29.8%), and SCC (28.1%) in a similar proportion to our study. 
This is supported in another Indian study where there was 38.8% of BCC, 27.1% of SGC, and 22.4% of SCC were reported.  Studies from various countries have reported different types and frequencies of malignant eyelid tumors, some of these reports have been concised in Table 4. [2-8,11-13,17-20,22-27]
In the present study, the mean age of patients with malignant tumors was above 62.2 (60 median age). This finding is in agreement with most of the studies by Wang J K et al (62.6 years median age),  A Bagheri et al (mean age >60 years) as well as the study by Vitaliano and Urbach et al who consider age an important risk factor in non-melanoma skin tumors.  The median age of presentation was 63 years for SGC, 60years for BCC, 57.5years for SCC, 55years for melanoma. lymphoma presented at 75 years and MCC at 52years in our study.
Worldwide, BCC is the most common eyelid malignant tumour. [2,4,5,8,22,25] The common malignancy in white population is Basal cell carcinoma.  Studies by Paul S et al, Cook BE Jr et al, Deprez et al reported 71.8%, 90.8% and 86% BCC respectively, which was the most common malignant tumor in their case series. [3-5] However reports from central India(Sihota et al (30%), Jahagirdar S S et al (44.5%), Kale SM et al (48.2%) [17,18,19] show a relatively lower incidence of BCC. In our cases series BCC accounted for 26.3% and was the 2nd most common malignant tumor.
Light pigmentation among whites is a risk factor for BCC; conversely, the BCC is rare among blacks. BCC is related to chronic and cumulative solar damage, and is more common in elderly and fair-skinned adults.  Its incidence is increasing worldwide by up to 10% a year. Approximately among 10 Caucasians 3 may develop a basal-cell cancer within their lifetime. [24,28]
The data reveal a significant increase in reported BCC among male patients compared to previous studies. Male to female ratio was 1.5:1 and this tumor also showed a preference for the lower eyelid in the present study, as also reported by Paul S et al and Wang C J et al. [3,24] In general, 20% of BCC occur in the periocular area of which half of the cases present in the lower eyelid, one-third in the medial canthus, 15% in the upper eyelid and 5% in the lateral canthus. 
In this study, the longest period between the onset of disease symptoms and referral was that of BCC (20 months) and the shortest time was related to lymphoma (2 months). Similar to our study, Takamura and Yamashita et al have reported that BCC had the longest time between the onset of the disease and referral (40 months) followed by SGC (11 months), SCC (10 months) and finally lymphoma (1 month).  BCC in the early stages is asymptomatic and progresses very slowly. Hence in any eyelid lesion a prompt biopsy is highly recommended. 
In the present study, with a 5 years follow-up of patients, there was 1 recurrent case of BCC after 10 months of initial surgery in an elderly male aged 85 years who had relatively large tumour measuring 1.5 cms. The recurrence rate for the tumor in the lower eyelid was 20% in our study.
The recurrence rate for the tumors in the lower eyelid was 14% in study by A Bagheri et al. 
Wang C J et al reported a recurrence rate of BCC (11.4%), and mean time of recurrence was 74 months. The mean time to recurrence or metastasis after primary treatment was longer for BCC than for SGC (47 months), SCC (30 months), or MM (22 months).  Hence BCC patients should be followed up for a longer period.
In the present study, SGC accounted for 31.6% of all malignant cases. SGC is more common in Asian population (South Asian and Indians) accounting for 27-40% of all eyelid malignancies. [22,23,29]
In the white population SGC is rare, accounting for 1-5.5% of all eyelid malignancies [12,19,22,29] Racial and genetic predisposition may probably play an important etiological role.  SGC is known to masquerade as chalazion in eyelid, hence the possibility of SGC should be considered in Asians presenting with persistent or recurrent chalazion. 
Thailand, India, Japan, China studies provide evidence, in favour of a higher proportion (30-40%) of occurrence of SGC. [13,17,18,19,23,24] Chinese studies have reported an incidence of 8-29% [22,24,30]
An incidence of 10% has been reported from Singapore accounting for less incidence of SGC.  In studies by Ni et al (U S) observed that SGC accounted for 32.7% of malignant eyelid tumors in Shanghai; whereas, at the Massachusetts Eye and Ear Institute in United states, SGC accounted for only 1.5% of malignant eyelid tumors. [24,30]
The reported incidence of SGC in USA varies from 0.5 to 5% of all lid carcinomas.  In the San Francisco population, despite having a significantly higher no of Asians, SGC was reported in only 7.3% of all eyelid malignancies than other parts of the United States. This result has confirmed that established Asian/Pacific Islander an-cestry is not a risk factor for developing sebaceous carcinoma as concluded by a recent study by Dasgupta et al [3,30]
In the present study, slight male predominance was noted in BCC and SCC (60%, 100% respectively). However SGC was noted to be predominant in females (83.3%).Various studies report large variations in the sex ratio. Sihota et al reports equal sex distribution for both SGC and BCC, but males were relatively often affected with SCC (60%). 
Wang et al. reported that though the incidence of lid malignancies was more in women than men (54.3% vs. 45.7%), there was a slight predominance of BCC in men (43 males, 36 females). Women outnumbered men in SGC (21 females, 9 males). 
Fonthip et al. found that most of the patients with eyelid tumors in their study were males. 
Sihota et al. found that the sex distribution was equal for both SGC and BCC, but males were relatively more often affected with SCC (60%) as also in the present study.  The variable sex incidence is possible due to the variations in the cohort of patients under study series.
The most common location of all malignant tumors in this study was the lower eyelid (74%), which has been reported in previous studies. [2,12,19,24] Patients with SGC showed very strong preference for upper eyelid (83.3%).The lower eye lid was also the most common site for all histological subtypes except SGC.
The predominance of BCC in the lower lid was reported in many studies, [1,12,22,24] as also observed in present study (100%). SGC is more common in the upper eyelid than the lower. [19,22,31] This preference is linked to relatively greater number of meibomian glands located in the upper lid (30) versus the lower lid(20).  Various studies have reported greater number of SGC cases in upper eye lid. [19,29]
The third most common tumor was squamous cell carcinoma (SCC) accounting for 21% of malignancies examined. Abe et al in Japan, reported SCC (48.1%) to be the most common eyelid cancer in their study, followed by BCC (32.6%) and SGC (13.5%). Various reports from India show the prevalence of SCC to be 14-28%. [17,18,19] In this study a preference for the lower lid (100%) and a male predominance was noted which is similar to the studies by Mary Ho et al and Sihota et al. [12,17]
Other cancers of note in this study included malignant melanoma (2 cases, 10.5%), lymphoma (1 case, 5.3%) and MCC (1 case, 5.3%). With the diagnosis of squamous cell carcinoma, lymphoma and malignant melanoma, a through systemic evaluation for regional or distant metastasis is always necessary.  The number of cases of malignant melanoma in present study were two accounting for 10.5% of malignant tumours, lower lid was involved in both and one case had multiple lesions.
Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin malignancy that occasionally affects the eyelid, with the potential for significant incidence of local recurrence, regional and distant metastasis [24,32] The number of cases in our present study was only one(5.3%) presented with a painless swelling over the left lower eyelid. Fine needle aspiration and cytology (FNAC), histopathology and immune histochemical (IHC) findings of the swelling and the pre auricular lymph node were diagnostic of MCC with regional metastasis. Current therapeutic regimen includes wide local excision, regional lymphadenectomy with adjuvant radiotherapy.
Ocular adnexal Lymphomas constitute (lymphomas of orbit, eyelids, conjunctiva, lacrimal gland and lacrimal sac) 2% of all extra nodal lymphomas.  The number of cases in our present study was only one(5.3%). Current therapeutic regimen includes wide local excision with adjuvant radiotherapy.
In summary all excised eyelid lesions must be submitted for histopathologic confirmation because there are some cases where clinical diagnosis does not match pathological diagnosis. To obtain 100% accuracy in clinical diagnosis, it should be strengthened by biopsy report. Early diagnosis remains essential for adequate functional and cosmetic lid reconstruction.
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COMMON MALIGNANT TUMORS:
A--Swelling over the left upper eyelid with ulceration-SGC.
B--Histopathological features of SGC--composed of foamy cells with multivacuolated cytoplasm and undifferentiated cells.
C-BCC--Swelling over the left lower eyelid with central ulceration and raised rolled edges.
D--BCC case Post lid reconstruction surgery.
RARE MALIGNANT TUMORS:
A1-Nodular firm non-tender swelling over left lower eyelid, in MCC case
A2 Histopathology features of MCC: Composed of uniform cells arranged in nests, lobules, sheets, trabecular pattern with scanty cytoplasm, round nucleus with dispersed chromatin & mitotic figures.
A3--Immunohistocytometry--Dot-like immunoreactivity for cytokeratin 20.
B1--Firm tender nodular swelling with overlying chemosis in left lowerlid.
B2--Round to oval large tumour cells with vesicular nucleus,pale pink cytoplasm, arranged in sheets, nest pattern, interspersed amidst are seen spider cells.
C1--Malignant melanoma--Two nodular, black pigmented, indurated lesions in lowerlid.
C2--Malignant melanoma--Post operative picture after tumour excision and lid reconstruction
C3--Nodular malignant melanoma is commonly composed of round to oval epithelioid cells with varying amounts of melanin pigment.
COMMON TYPES OF BENIGN TUMOURS:
A--EPIDERMOID CYST. B--DERMOID CYST. C--NEVUS. D--PAPILLOMACOMMON.
[GRAPHIC 1 OMITTED]
[GRAPHIC 2 OMITTED]
Hemalatha Krishnamurthy (1), Tanushree V (2), Venkategowda H. T. (3), Archana S (4), Mobin G (5), Aylette D'Silva (6), Bharathi M (7), Savita Patil (8)
(1.) Hemalatha Krishnamurthy
(2.) Tanushree V
(3.) Venkategowda H. T
(4.) Archana S,
(5.) Mobin G
(6.) Aylette D'Silya
(7.) Bharathi M,
(8.) Savita Patil
PARTICULARS OF CONTRIBUTORS:
(1.) Assistant Professor, Department of Ophthalmology, MMC & RI, Mysore.
(2.) Senior Resident, Department of Ophthalmology, MMC & RI, Mysore.
(3.) Professor and HOD, Department of Ophthalmology, MMC & RI, Mysore.
(4.) Assistant Professor, Department of Pathology, Melaka Manipal Medical College, Manipal University.
(5.) Junior Resident, Department of Ophthalmology, MMC & RI, Mysore.
(6.) Junior Resident, Department of Ophthalmology, MMC & RI, Mysore.
(7.) Professor and HOD, Department of Pathology, MMC &RI.
(8.) Junior resident, Department of Ophthalmology, MMC & RI
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Hemalatha K, #904/12, Murthy Nilaya, Nanju Mallige Circle, Mysore-570004. Email: email@example.com
Date of Submission: 14/09/2014.
Date of Peer Review: 15/09/2014.
Date of Acceptance: 29/09/2014.
Date of Publishing: 04/10/2014.
Table 1: HISTOLOGICAL SPECTRUM AND FREQUENCIES OF BENIGN EYELID TUMOURS Histopathological No.(Percentage) type of cases Epidermal cyst 66 (30.50) Dermoid 30 (13.80) Intradermal nevus 28 (12.90) Compound nevus 10 (4.60) Papilloma 14 (6.50) Haemangioma 09(4.10) Verruca Vulgaris 08 (3.70) Trichoepithelioma 04 (1.85) Seborrheic Horn 02 (0.90) Seborrheic Keratosis 02 (0.90) Benign Fibrous Cystiocytoma 01 (0.46) Apocrine Hydrocystoma 02 (0.90) EccrineSpiradenoma 01 (0.46) Pseudoriforus Cyst 01 (0.46) Lipoma 01 (0.46) Fibroma 01 (0.46) Pilomatrixoma 01 (0.46) Neuroma 01(0.46) Neurofibroma 01 (0.46) Microphthalmos with lower 01(0.46) lid unilocular cyst Others benign lesions 32(14.8) Table 2: Histopathological types of Malignant Tumors & Incidence Tumor Type No.(Percentage) Sebaceous Gland Carcinoma 6(31.6%) Basal Cell Carcinoma 5(26.3%) Squamous Cell Carcinoma 4(21.0%) Malignant Melanoma 2(10.5%) Lymphoma 1(5.3%) Merkel cell carcinoma 1(5.3%) Table: 2.A. Common Malignant Eyelid Tumours reported from various Asian Countries. SGC is more common in Asian population (South Asian and Indians) accounting for 27-40% of all eyelid malignancies Author, Present Abdi et Lin et al, Sihota et country, n= study al Taiwan, al (India) number of (South (India) (n=1166) (n=178) malignant India) (n=85) cases. (n=19) BCC (%) 26.3 38.8 65.1 29.8 SGC (%) 31.6 27.1 7.9 32.6 SCC (%) 21 22.4 12.6 28.1 Malignant 10.5 3.5 2 2 melanoma (%) Lymphoma (%) 5.3 MCC (%) 5.3 Others (%) 8.2 4 7.5 Author, Xu XL, Pornpanich, Obata H, country, n= Beijing, Thailand, Japanese, number of (n=2639) (n=32) (n=24) malignant cases. BCC (%) 41 40.62 37.5 SGC (%) 39 37.5 37.5 SCC (%) 5 6.25 Malignant 4 9.3 melanoma (%) Lymphoma (%) 9 16.6 MCC (%) Others (%) 6.25 8.3 Table 3: Common Benign Tumours in various Countries Type of Present Hsu & Abdi Deprez Kerstein benign study, Lin et et al, et al, et al, tumour India, al, India US US Taiwan Epidermal cyst 31.6% 23.1% 22.2% Nevus 17.5% 9% 12.3% 20% Dermoid cyst 13.8% 17.9% 16.4% Papilloma 6.5% 11.5% 13.1% 26% 43.9% Seborrhoeic 0.9% 21% Keratosis Hydrocystoma 0.9% 8% Vascular 4.1% 21.3% tumour Neural tumour 0.9% 18% Lipogranuloma Xanthoma 6% Chalazion Warts 3.7% Type of Obata Paul S Mary Ni et Chi & YH.AL- benign H et et al, Ho al, Beak Faky, tumour al, San et al, China et al, Saudi Japan Fransisco Hong Korea Kong Epidermal cyst 10.9% 7% 8% 5.4% 9% Nevus 21.9% 12.2% 31% 24.4% 57.1% 8.1% Dermoid cyst Papilloma 9.3% 8.6% 27.9% 20.3% Seborrhoeic 14% 19.7% 15% 4.9% Keratosis Hydrocystoma 8.6% 29.3% Vascular 0.9% tumour Neural tumour Lipogranuloma 13.7% Xanthoma 3.6% Chalazion 21.6% Warts 3.38% 22.4% 3.1% Table: 4.B. Common Malignant Tumours reported from Western Countries and from Tehran BCC is the commonest malignant tumour reported from western countries Author, Paul et al, Deprez, Ni et al, country, n= San Switzerland, US, number of Fransisco, (n=880) (n=1543) malignant (n=206) cases. BCC (%) 71.8 86 92.5 SGC (%) 7.3 3 1.5 SCC (%) 9.7 7 4.6 Malignant melanoma 9.2 1.1 (%) Lymphoma (%) MCC (%) Others (%) 0.3 Author, Weiner et Cook B E, Bagheri A country, n= al6 Minnesotaa, et al, number of (Australia) (n=174) Tehran, malignant (n=475) (n=100) cases. BCC (%) 88.8 90.8 83 SGC (%) 3.8 6 SCC (%) 7.4 8.6 8 Malignant melanoma 0.6 (%) Lymphoma (%) MCC (%) Others (%)
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Krishnamurthy, Hemalatha; Tanushree, V.; Venkategowda, H.T.; Archana, S.; Mobin, G.; D'Silva, Aylett|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Oct 6, 2014|
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