High-dose-rate intraluminal brachytherapy during preoperative chemoradiation for locally advanced rectal cancers

AIM: To determine the feasibility and safety of high dose rate intraluminal brachytherapy (HDR-ILBT) boost during preoperative chemoradiation for rectal cancer.

METHODS: Between 2008 and 2009, thirty-six patients with locally advanced rectal cancer (≥ T3 or N+), were treated initially with concurrent capecitabine (825 mg/m² oral twice daily) and pelvic external beam radiotherapy (EBRT) (45 Gy in 25 fractions), then were randomized to group A; HDR-ILBT group (n = 17) to receive 5.5-7 Gy × 2 to gross tumor volume (GTV) and group B; EBRT group (n = 19) to receive 5.4 Gy × 3 fractions to GTV with EBRT. All patients underwent total mesorectal excision.

RESULTS: Grade 3 acute toxicities were registered in 12 patients (70.6%) in group A and in 8 (42.1%) in group B. Complete pathologic response of T stage (ypT0) in group A was registered in 10 patients (58.8%) and in group B, 3 patients (15.8%) had ypT0 (P < 0.0001). Sphincter preservation was reported in 6/9 patients (66.7%) in group A and in 5/10 patients (50%) in group B (P < 0.01). Overall radiological response was 68.15% and 66.04% in Group A and B, respectively. During a median follow up of 18 mo, late grade 1 and 2 sequelae were registered in 3 patients (17.6%) and 4 patients (21.1%) in the groups A and B, respectively.

CONCLUSION: HDR-ILBT was found to be effective dose escalation technique in preoperative chemoradiation for rectal cancers, with higher response rates, downstaging and with manageable acute toxicities.

Role of immunofluorescence and electron microscopy in the evaluation of renal biopsies in nephrotic syndrome in a developing country

To determine the role of immunofluorescence (IF) and electron microscopy (EM) in the evaluation of renal biopsies in a developing country, the authors carried out a study in 200 patients with nephrotic syndrome. Renal biopsies were studied by light microscopy, IF, and EM. IF study was useful in all, being essential in 23.5% and helpful in remaining cases. EM was useful in 94.5% cases, being essential in 43% and helpful in 51.5% cases. The results demonstrate that IF and EM are essential in the evaluation of renal biopsies in nephrotic syndrome and these should be employed in the pathologic evaluation of renal biopsies.

Pattern of morphology in renal biopsies of nephrotic syndrome patients. Correlation with immunoglobulin and complement deposition and serology

OBJECTIVE

To determine the morphological pattern in renal biopsies from nephrotic patients and their correlation with immunoglobulin and complement deposition as detected by immunofluorescence microscopy (IMF) and serology to arrive at correct diagnosis of glomerulonephritis (GN).

METHODS

The study was carried out at the departments of Immunology and Histopathology, Sindh Institute of Urology and Transplantation (SIUT) from April 2007 to March 2008. A total of 200 patients, including children and adults were included. All patients presented with nephrotic syndrome (NS). Clinical and laboratory investigations including serology were noted, renal biopsies performed and studied by light and immunofluorescence microscopy (IMF).

RESULTS

Of 200 patients, 74 (37%) were children (< or = 18 years) and 126 (63%) adults (> or = 19 years). Mean age of children was 11.34 +/- 4.85 years (range 3-18 years) and that of adults was 35.44 +/- 11.4 years (range: 19-70 years). The total percent change in L/M diagnosis after serological tests was 11.5% and after IMF studies, 23.5%. Combined serologic and IMF studies lead to 35% change in L/M diagnosis of the renal biopsies in nephrotic syndrome patients.

CONCLUSION

Our results demonstrate that the ancillary techniques of IMF microscopy and serology are indispensable in the elucidation of final specific diagnosis causing nephrotic syndrome in a substantial number of cases and these should be employed routinely in the pathologic evaluation of renal biopsies. The study emphasizes the importance of combined approach in the investigation of renal biopsies in nephrotic syndrome.

Histopathological spectrum of childhood nephrotic syndrome in Pakistan

BACKGROUND

There is no information in international literature on the pattern of glomerulopathies in children with idiopathic nephrotic syndrome (INS) in Pakistan. We undertook this study to determine the pattern of glomerulopathies based on renal biopsies studied by light (LM), immunofluorescence (IF), and electron microscopy (EM).

METHODS

The study was conducted at Sindh Institute of Urology and Transplantation (SIUT), Karachi over 12 years (1996-2008). All children (<or=18 years) with INS in whom renal biopsy was performed were included. Renal biopsies were studied by LM, IF, and EM.

RESULTS

Of 538 children, 347 (64.4%) were male and 191 (35.5%) were female. Mean age was 9.79 +/- 4.59 years. The histopathological lesions comprised: minimal change disease (MCD) and its variants, 43.8%; focal segmental glomerulosclerosis (FSGS), 38.14%; membranous glomerulonephritis (GN) (MGN), 7.96%; mesangioproliferative GN (MesPGN), 4.81%; mesangiocapillary GN (MPGN), 3.14%; IgA nephropathy (IgAN), 1.11%; and other rare lesions.

CONCLUSION

MCD and its variants are the leading cause of overall INS in children, followed by FSGS, which is the predominant pathology in steroid-resistant and adolescent nephrotic syndrome (NS). Our data are in accordance with recent series from around the world with similar biopsy indications. The study defines the true pattern of glomerulopathies in childhood INS for the first time in Pakistan.

Adrenal myelolipoma: a report of three cases and review of literature

Adrenal myelolipoma is a rare and benign tumour composed of mature adipose tissue and haematopoietic elements that resemble bone marrow. It is mostly discovered incidentally on imaging of abdomen done for non adrenal related reasons or at autopsy. Usually asymptomatic, but has been reported to present with symptoms such as flank pain resulting from tumour bulk, necrosis or spontaneous retroperitoneal haemorrhage. Symptomatic tumours, growing tumours or tumours larger than 10 cm should be excised surgically. We report cases of 3 male patients presenting with flank pain and upper pole renal masses. All three were treated surgically with adrenalectomy. Myelolipoma was confirmed in all three on histology.

Evaluation of pre transplant T-cell activation status by soluble CD 30 determination

OBJECTIVE

To evaluate the utility of serum CD30 (sCD30) levels as predictor of early acute graft rejection in live related renal transplant programme.

METHODS

This prospective study included 50 consecutive renal transplant recipients who received their first live related renal allograft at the Sindh Institute of Urology and Transplantation (SIUT) between October 2006 and March 2007. Blood samples were obtained one day before transplantation and on the third and fourteenth posttransplant days. Blood samples were also obtained from 50, age and sex matched healthy control individuals. Levels of serum sCD30 were measured by Enzyme Linked Immunosorbent Assay (ELISA).

RESULT

Donor-recipient blood group matching was identical in all patients. Pre-transplant lymphocyte crossmatch for T and B cells was negative, and panel reactive antibodies (PRA) were 0% for all recipients. The mean age of recipients was 31.6 +/- 10.23 years (range 5 to 55 years), while mean donor age was 32.74 +/- 8.48 years (range 21-50 years). Eleven (22%) recipients and donors were HLA identical while remaining (78%) were one haplotype match. Average serum sCD30 pre-transplant levels (37.8 +/- 4.97U/ml) were significantly higher than those of healthy individual's mean value of 8.48 +/- 4.97 U/ml, (P = 0.001). Eight (16%) patients developed acute rejection episode during this follow up period. Rejections were described and classified according to BANFF 97 classification.

CONCLUSION

In this small single center study the serum levels of sCD30 did not show any significant difference between rejection and non rejection group in our transplant population.

Spectrum of glomerulonephritides in adults with nephrotic syndrome in Pakistan

BACKGROUND

There is currently little information in literature about the pattern of glomerulonephritides (GN) in adults with nephrotic syndrome in this part of the world, particularly that involving the use of immunofluorescence (IMF) and electron microscopy (EM). A few studies reported are based on light microscopic study alone and hence do not reflect the true pattern of GN underlying nephrotic syndrome. We carried out this study in the Department of Histopathology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan to determine, for the first time, the true pattern of GN in adult nephrotic patients from Pakistan. SIUT is a tertiary care center for renal and urologic disease in Pakistan. The Histopathology Laboratory of SIUT is equipped with all the modalities, including EM, required for precise diagnosis of glomerular disease.

METHODS

This is a retrospective clinicopathologic study involving retrieval of clinical and pathological data from a review of original renal biopsy reports of adult patients with nephrotic syndrome who presented at the adult nephrology clinic of SIUT from July 1996 till July 2006. Two cores of renal tissue were routinely obtained. One core was fixed in 10% buffered formalin and processed for light microscopy; the other core was divided into two halves, for EM and the IMF study.

RESULTS

A total of 316 adult patients were included. Of these, 201 (63.6%) were male and 115 (36.4%) were female. Mean age was 28.4 +/- 10.51 years with a range of 16-78 years. The spectrum of pathological lesions in the adult nephrotic population was wide and comprised focal segmental glomerulosclerosis (FSGS) (39.87%), followed by membranous GN (MGN) (26.58%), minimal change disease (MCD) (14.82%), mesangiocapillary GN (4.3%), mesangioproliferative GN (4.11%), post-infectious GN (2.84%), IgA nephropathy (2.53%), and other rare lesions.

CONCLUSIONS

Results from this study indicate that FSGS is the single most common cause of nephrotic syndrome in adult nephrotic patients, followed by MGN, and MCD. Our data are similar to those reported in recent series from the US. The study defines the pattern of glomerular disease in adult nephrotic patients for the first time in this region, because it is based on light microscopy, serology, IMF, and EM findings.

Rectal malakoplakia presenting as a mass and fistulous tract in a renal transplant patient

Malakoplakia (MK) is a rare, chronic inflammatory disorder with characteristic morphologic features. It most commonly involves urogenital organs but can affect any organ system in the body. Gastrointestinal tract is the second common site of involvement. It commonly occurs in nontransplant patients but transplant patients are also vulnerable to it. We present a case report of a forty year old male renal transplant patient, who received a kidney from his brother with 1 haplotype and 4 antigen match. He was on regular post transplant follow up with stable graft function. Fifteen months post transplant he presented with the complaint of painful defecation, a swelling in the perianal region and inability to sit down properly. Biopsy examination showed malakoplakia with characteristic Michaelis-Gutmann bodies. Culture of the tissue grew E Coli. Immunosuppression therapy was curtailed and patient was started on ciprofloxacin 500mg OD for 6 months. The lesions regressed completely after six months of the above therapy and the patient became completely symptoms free.

Crescentic glomerulonephritis associated with bacterial endocarditis--antibiotics alone may be sufficient. A case report

Crescentic glomerulonephritis complicating the course of bacterial endocarditis carries a poor prognosis. Ideal treatment strategy is not clearly defined. In addition to antibiotic treatment, plasmapheresis and steroids have been used with variable results. Here we report a case of 40-year old female who was referred because of generalized body swelling and decrease urine output associated with low grade fever on and off for two to three months. She was diagnosed to have acute renal failure secondary to tricuspid valve endocarditis. Staph aureus was isolated from blood culture and renal biopsy showed crescentic glomerulonephritis. She received dialysis support and antibiotics and had complete recovery of renal function 6 weeks after initiation of therapy. Eradication of infection with antibiotics treatment may be sufficient for resolution of crescentic glomerulonephritis associated with infective endocarditis in some cases.

Ampullary ganglioneuroma: an unusual feature of neurofibromatosis type 1--a case report

The case of a 65 year old man is presented. He had a history of dyspepsia and was diagnosed as neurofibromatosis clinically. Upper G.I. endoscopy showed thickened folds in duodenum. A polyp was seen at the junction of D1 and D2 adjacent to the ampulla. Duodenal biopsy results were suggestive of ganglioneuroma.