Primary malignant melanoma in ovarian cystic teratoma

BACKGROUND

Malignant degeneration of benign cystic teratoma of the ovary is rare. Occurrence of melanoma in an ovarian cystic primary teratoma in the absence of a demonstrable extraovarian primary is even rarer. We describe here one such case.

CASE

A 42-year-old nulliparous woman underwent laparotomy for a cyst in the right ovary. Histopathological examination of the specimen revealed malignant cystic teratoma with the presence of a melanoma component. There was no evidence of extraovarian primary melanoma on clinical examination. Two years later, she presented with lung metastasis and underwent left pneumonectomy. Histopathology confirmed metastatic melanoma. Postoperatively, she received combination chemotherapy using cisplatin and dacarbazine. She is on regular follow-up and continues to be disease-free, 18 months after treatment.

CONCLUSION

Primary malignant melanoma in cystic teratoma of the ovary is extremely rare. We could find only 19 such cases on review of the literature. Clinical presentation is similar to that of primary epithelial ovarian cancer. Surgery remains the mainstay of treatment. Use of cisplatin and dacarbazine may be considered in a patient with metastatic disease.

Omentum autotransplantation in thromboangiitis obliterans: report of three cases

Thromboangiitis obliterans (TAO), also known as Buerger's disease, is an important cause in India of chronic arterial occlusion of the limbs. The current modalities of therapy do not provide adequate relief to a large number of these patients. An omentum autotransplantation to the lower limbs was performed in three patients as a limb salvage procedure. The initial results with up to a year of follow-up are so far encouraging.

Retrieval of lost Copper-T from the rectum

A case of lost Copper-T lying partly in the rectal lumen and its removal through the rectal route is described. This case emphasises the importance of rectal examination in the case of lost intra-uterine contraceptive device (IUCD) and highlights the possibility of safe retrieval of an IUCD through the rectal route even when it is partly embedded in the rectal wall.

Laparoscopic hernia repair--what are the results?

The two widely practised laparoscopic groin hernia repairs are: a) trans-abdominal preperitoneal (TAPP) and b) trans-extraperitoneal preperitoneal (TEPP) approaches. Early results are encouraging with both the techniques being associated with low recurrence rates (0% to 2%) comparable to the best, reported for standard open repair (Shouldice and Lichtenstein's). Other complications are higher in the beginning following laparoscopic hernia repair compared to the conventional method. These complications are related to the learning curve and expected to come down significantly with increasing experience of surgeons. Laparoscopic repair of recurrent groin hernia appears to be considerably superior to the conventional technique. The recurrence rates following conventional repair of recurrent groin hernias are between 1.5% and 35% (Table I) compared to none for laparoscopic repair of recurrent inguinal hernias. The disadvantages of laparoscopic repair include greater technical difficulty, higher incidence of serious complications and increased cost. Sutured open repair is associated with high postoperative discomfort, greater difficulty of repairing recurrent hernia with higher societal cost (due to prolonged time-off from work for 12% to 57% of patients operated for various open technique-Table II). The techniques of laparoscopic hernia repairs are nearly standardised today. Laparoscopic surgeons have an obligation to offer the new alternative and to ensure that it is safely used. Laparoscopic repair is another technique used for the repair of inguinal hernias, which is going to stay as a safe and effective alternative to open repair as the learning curve is over. There is an urgent need to have well-designed prospective randomised trials in the near future.

Spontaneous rupture of spleen in viral hepatitis A

A twenty-five year old man presented with history of fever, malaise and jaundice and developed a spontaneous rupture of the spleen during hospital admission. Investigations revealed deranged liver function tests and positive serology for hepatitis A.

Role of hepatobiliary scintigraphy in management of postoperative bile leak into the lesser sac

A case with bile leak into the lesser sac of peritoneum is reported. Although bile leak following biliary surgery or trauma is not uncommon, isolated bile leak into the lesser sac is rare. This information may be vital for appropriate placement of the drainage tube in the abdomen. A hepatobiliary study, as reflected in this report, is extremely useful in guiding the surgeon in this respect.

Cyclical mastalgia--is it a manifestation of aberration in lipid metabolism?

Several therapeutic and investigative studies suggest the possibility of the role of lipid profile aberrations in the pathophysiology of cyclical mastalgia. This prospective study is aimed to look for such aberrations. Fifty-seven patients of benign breast disease were included in this study who were symptomatic for at least 6 months prior to presentation. Detailed serum lipid profile work up was performed on day 1, 15 and 25 of menstrual cycle. The patients with symptoms of maximal severity (or limited to) during leuteal phase of menstrual cycle were included in group I (n = 32). Those who had mastalgia, but did not have above mentioned cyclical variation, were included in group II (n = 25). Since noncyclical mastalgia is a group of heterogeneous disorders of varied etiology, the patients in group II were treated as controls. At day 25, there was an elevation in mean values of HDL-C (P = 0.03) and HDL-C/LDL-C ratio (P = 0.01), and reduction in TC/HDL-C ratio (P < 0.03), in group I. This has not been the case with group II patients. When the patients of mastalgia were treated with low fat dietary regimen, there was a significant difference in the responses of these two groups (P value < 0.0001). Based on the results of lipid profile study and dietary intervention, we conclude that cyclical mastalgia is an entity which is distinctly different from noncyclical mastalgia and needs a different therapeutic approach. Our data, both investigative and therapeutic, suggests that cyclical mastalgia may be a result of cyclical aberrations in lipid metabolism, and the physiological treatment in the form of an appropriate dietary regimen holds a considerable promise.

Current practice in biliary surgery: the Indian scenario

OBJECTIVE

Documentation of current biliary surgical practices of surgeons in India.

METHODS

A postal questionnaire survey of the consultants in surgery in all the medical colleges in India was done to establish their current practice regarding cholecystectomy and to assess the influence of recent studies on their practice.

RESULTS

The response rate was 23% (264/1127). About half of the surgeons did both ultrasonography and oral cholecystography for the diagnosis of cholelithiasis. Acute cholecystitis was managed conservatively by 80% of surgeons. Antibiotics were used by all surgeons but 87% of them used antibiotics for more than one day. Peroperative cholangiography was done in all cases by 20% of those who had the facilities available. Incidental appendectomy was done by 26% of surgeons. Drain was used in all cases by 78% of surgeons. Patients were discharged after suture removal by 77% of surgeons.

CONCLUSIONS

The practices of the Indian surgeon surveyed were against the recommendations in current literature which did not seem to have had much impact on them regarding their practice of biliary surgery.

Efficacy of low fat diet in the treatment of benign breast disease

BACKGROUND

Previous studies have shown that lipid abnormalities have a role in the pathogenesis of benign breast disease. However, few investigators have tried to reduce dietary fat to treat this disorder.

METHODS

Between 1990 and 1993, we conducted a prospective cohort study to find out the efficacy of a low fat diet (less than 15% fat-derived calories) in the treatment of benign breast disease in patients who had been symptomatic for 6 months or more. The study was conducted in two phases. In the first phase 36 patients were alternately assigned to control and treatment groups for 6 months and in the second phase 121 patients (including all those in phase I) were given treatment (median follow up 25 months, range 3 to 39 months). Detailed lipid profiles were studied at the time of presentation and at 4 and 5 months.

RESULTS

Phase I results showed that after 6 months none of the patients in the control group had experienced any alteration in their symptoms and signs but in the treatment group 12 out of 17 improved. In phase II improvement in pain (68 out of 97; 70%), nodularity (51 out of 79; 64%) and discharge (15 out of 19; 80%) was seen. There was a significant decline in the mean values of total cholesterol and high-density lipoproteins at the end of 5 months of treatment.

CONCLUSION

A low fat diet improves the symptoms as well as the lipid profile in patients with benign breast disease.

Thoracoscopic management of malignant pleural effusion

The results of thoracoscopic biopsy and talc pleurodesis in the management of malignant pleural effusions, is analysed. The study population consisted of 213 patients. Pre-operative cytology was positive in only 27% of patients; the diagnostic yield using thoracoscopic biopsy was 91.5%. (Sensitivity 99%; specificity 100%; positive predicted value 100%; negative predicted value 88%). Talc pleurodesis at thoracoscopy produced symptomatic improvement in 93% of patients. Post-operative complications occurred in 3.7% and there was a 2.3% mortality. Recurrent effusion was not a significant clinical problem. Thoracoscopy enhances the accuracy of diagnosis of pleural effusions; simultaneous talc pleurodesis has a high therapeutic success.

Malignant insulinoma presenting with recurrent episodic loss of consciousness

A 57 year old male presented with episodic behavioural abnormalities and loss of consciousness for 2 years. His fasting blood glucose was 20 mg/dl and corresponding insulin level 119 uU/ml. His EEG showed intermittent rhythmic delta activity. Abdominal CT scan revealed an enhancing mass in the tail of the pancreas and secondaries in the liver. After distal pancreatectomy, resection of the left lobe of the liver and chemotherapy, the hypoglycaemic spells subsided. Histopathology revealed an islet cell tumour with metastases in the liver. Episodic neurobehavioural dysfunction should alert towards the possibility of hypoglycaemia.

A case of follicular small cleaved cell lymphoma with t(14;18) and t(8;11)

Follicular small cleaved cell lymphoma is a common B-cell lymphoma exhibiting a t(14;18)(q32;q21) chromosomal translocation, which has been found in most cases studied. In our case of follicular small cleaved cell lymphoma, the chromosome translocation 14;18 was observed. This case also exhibits a second consistent chromosomal translocation, t(8;11)(p21;q13), along with t(14;18).

The drinking habits of Sikh, Hindu, Muslim and white men in the West Midlands: a community survey

Men born in India but living in Britain have higher than expected treated prevalence rates of alcohol-related disorders. A community survey of random samples of 200 each of Sikh, Muslim and Hindu men and 200 white English-born men, matched for age, were interviewed using a structural questionnaire containing a retrospective drinking diary. Sikhs were most likely to be regular drinkers followed by whites and Hindus. The very few Muslim men who drank consumed the most alcohol on average. The frequently reported pattern of an inverse relationship between drinking and age was found for white men but not among Sikhs and Hindus. In both these groups older men reported consuming more alcohol than did young men. However, age was confounded with generation: heavier levels of consumption were reported by Sikhs and Hindus born in India than by Sikhs and Hindus born in Britain. Among regular drinkers Sikhs had higher average Alcohol Problem Scale Scores than did white men or Hindus. The highest average scores were recorded for the (few) Muslim regular drinkers (who also consumed the most alcohol). A clear association with religious observance was found for all three Asian groups and for the white men. No religious Muslims drank at all, and a relatively small proportion of the other groups who were regular church/Temple attenders drank regularly.

Fine needle aspiration cytology as a preliminary diagnostic procedure for asymptomatic cervical lymphadenopathy

Fine needle aspiration cytology (FNAC) was used as a preliminary diagnostic procedure in evaluating discrete, asymptomatic cervical lymphadenopathy of more than four weeks duration. Benign pathologies were encountered in 294/359 patients (82%); of these 86% had tuberculosis. Even in the elderly, a large number of patients (25/78) harboured tubercular lymph glands. FNAC obtained adequate material for cytologic diagnosis in 97.5% and had an overall accuracy rate of 97%. Malignancy was correctly diagnosed in 100%; in tuberculosis the accuracy rate of 96% with a 3.5% false negative results. FNAC is reliable as the initial evaluating procedure even in benign disorders; it is also cheap, speedy and easy to perform, with no complications, making it suitable for wider application in developing countries with scant resources.