Follicular dendritic cell tumour of tonsil - is it an under-diagnosed entity?

Neoplasms of follicular dendritic cells are uncommon and while majority of them occur in lymph nodes, they are increasingly recognized at varied sites such as abdominal viscera. Tonsil is the most common extra nodal site for occurrence of FDCT in the head and neck region. We describe three cases of follicular dendritic cell tumour occurring in the tonsil.

Desmoplastic small round cell tumor: Extra abdominal and abdominal presentations and the results of treatment

BACKGROUND

Desmoplastic small round cell tumor (DSRCT) is a rare malignant neoplasm of adolescent males. Current multimodality treatment prolongs life and rarely achieves cure.

AIM

To review the presenting features, histopathology and outcome of 18 patients with DSRCT treated at a single institution.

SETTING AND DESIGN

This is a retrospective observational study of patients with DSRCT who presented at the Tata Memorial Hospital between January 1994 to January 2005.

MATERIALS AND METHODS

Eighteen patients of DSRCT seen during this period were evaluated for their clinical presentation, response to chemotherapy and other multimodality treatment and overall survival. The cohort of 18 patients included 11 males (61%) and 7 females (39%) with a mean age of 16 years (Range 1(1/2)--30 years). Majority (83%) presented with abdomino-pelvic disease. The others, involving chest wall and extremities. There were 6 patients (33%) with metastatic disease at presentation.

RESULTS

The treatment primarily included a multimodality approach using a combination of multiagent chemotherapy with adjuvant surgery and radiotherapy as applicable. A response rate of 39% (CR-1, PR-6), with chemotherapy was observed. The overall response rate after multimodality treatment was 39% (CR-5, PR-2). The overall survival was poor except in patients who had complete excision of the tumor.

CONCLUSION

0 Abdomino-pelvic site was the commonest presentation, the disease can occur at other non-serosal surfaces also. Despite aggressive treatment the outcome was poor. However, complete surgical excision seems to provide a better survival.

Postoperative cerebellar herniation in a large intrapetrous aneurysmal bone cyst

An 18-year old boy presented with a tumour involving a large part of the petrous bone. A radical resection of a petrous bone 'aneurysmal bone cyst' was achieved. A large defect in the dura adjoining the posterior surface of the petrous bone was made during surgery. Post-operative MR imaging showed complete tumour resection but herniation of cerebellum into the operative defect, a phenomenon probably assisting to seal the site of cerebrospinal fluid fistula.

A prospective evaluation of the management of acute pyelonephritis in adults referred to urologists

In order to assess whether it is appropriate and clinically efficient to admit adults with 'clinically diagnosed' acute pyelonephritis (APN) under urologists, as is current practice in many NHS hospitals, a prospective study was undertaken over nine months in an NHS teaching hospital. Thirty-nine patients with clinical APN were admitted to the urology unit; all were pyrexial and 30 (77%) had typical features of rigor, flank pain and irritative lower urinary tract symptoms. Twenty-one (54%) had positive urine cultures, 31 (79%) had parenteral antibiotics, while another three (7%) had oral agents initially. The remaining five (14%) were continued on agents initiated by their GPs before admission. Thirty-three (85%) had imaging procedures with eight significant anomalies being noted. Urgent invasive intervention was required in only four (10%) patients; length of stay varied from one to 25 days. Uncomplicated moderate to severe APN in adults may be treated safely without the need for admission to the urology unit, either in the outpatient setting or on an acute admissions observation ward. Complicated cases requiring intervention can be transferred to the urologist once recommended investigations have been undertaken. This care pathway may help to reduce cancellations of elective urological cases and is likely to be more cost-effective for the NHS by reducing unnecessary admissions.

Reversible hypertension in a young female: ureteric obstruction due to endometriosis

We present the case of a young female who, upon investigation for hypertension, was found to have a ureteric stricture secondary to endometriosis. After excision of the stricture and an end-to-end ureteric anastomosis the patient's blood pressure returned to normal. This case highlights the need to investigate fully hypertension in young people and to consider the possibility of endometriosis in any female who presents with obstructive uropathy.

Transurethral prostatic resection or laser therapy for men with acute urinary retention: the ClasP randomized trial

PURPOSE

Transurethral resection of the prostate is the standard operation for acute urinary retention, although laser prostatectomy is reportedly effective and safe. The ClasP (conservative management, laser, transurethral resection of the prostate) study compared transurethral prostatic resection and noncontact neodymium (Nd):YAG visual laser assisted prostatectomy for treatment of acute urinary retention.

MATERIALS AND METHODS

This study was a multicenter randomized controlled trial, analyses were by intention to treat and followup was at 7.5 months after randomization. Primary outcomes were treatment failure, and included International Prostate Symptom Score, International Prostate Symptom Score quality of life score, residual urine and flow rate. Secondary outcomes included complications, and duration of catheterization and hospitalization.

RESULTS

A total of 148 men were randomized to transurethral prostatic resection (74) and laser (74). There were fewer treatment failures after prostatic resection (p = 0.008) and fewer men after resection required secondary surgery for poor results (1 versus 7, p = 0.029). Maximum flow rates after transurethral prostatic resection were better than after laser (mean difference 4.4 ml. per second). Comparison of symptom and quality of life scores demonstrated that any clinically significant advantage for laser could be ruled out. Patients stayed a mean of 2 extra days in the hospital after resection. The duration of catheterization was greater after laser but significantly fewer major treatment complications were found with laser therapy.

CONCLUSIONS

Transurethral prostatic resection was more effective, resulted in fewer failures than laser treatment and remains the procedure of choice for men with acute urinary retention.

Childhood proptosis: the invaluable but overlooked peripheral blood smear

Two cases of granulocytic sarcoma presenting as childhood proptosis are described. This highlights the significance of peripheral blood smear examination in establishing the diagnosis of Acute Myeloid Leukaemia (AML).

Burkitt's lymphoma of stomach: A case report and review of literature

Primary gastrointestinal non-Hodgkin's lymphoma is a distinct clinicopathological entity. This is the commonest site of all extranodal lymphomas. Non-endemic Burkitt's lymphoma (high-grade, small non-cleaved lymphocytic type) is rare in non-HIV adult population. We hereby report Burkitt's lymphoma of stomach in a non-HIV adult. Gastric and lymph node biopsy confirmed the diagnosis. Patient was treated using a third generation chemotherapy protocol without any surgical resection. The patient relapsed within 3 months of completion of primary treatment and died of progressive disease.

Bilateral superselective arterial microcoil embolisation in delayed post-traumatic high flow priapism

High flow arteriogenic priapism is uncommon and usually occurs after trauma to the genitoperineal area. The onset of prolonged erection can be delayed and is often relatively pain free. Arteriography in this case illustrated the causative bilateral arteriocavernosal fistulae and pseudoaneurysms. Treatment consisted of staged bilateral superselective metallic microcoil embolisations, resulting in prompt detumescence. There were no complications. The patient had normal erectile function six months later. Recent concerns about erectile dysfunction with the bilateral use of permanent metallic coils appear to be unfounded.

A prospective randomized trial comparing transurethral resection of the prostate and laser therapy in men with chronic urinary retention: The CLasP study

PURPOSE

We assessed the effectiveness of laser therapy versus transurethral prostatic resection in men with symptomatic chronic urinary retention secondary to benign prostatic enlargement.

MATERIALS AND METHODS

This trial was multicenter, pragmatic and randomized. Analysis was done by intent to treat. Laser therapy involved neodymium:YAG noncontact visual prostate ablation, while transurethral prostatic resection was performed by standard electroresection. Patients were included in our study if they reported moderate to severe lower urinary tract symptoms with an International Prostate Symptom Score (I-PSS) of 8 or more, benign prostatic enlargement and a persistent post-void residual urine volume of more than 300 ml. Followup was 7.5 months. Primary outcome measures included the I-PSS, I-PSS quality of life score, maximum urinary flow and post-void residual urine volume. Secondary outcome measures included treatment failure, complications, hospital stay and catheterization time.

RESULTS

A total of 82 patients agreed to be randomized to receive laser therapy (38) or transurethral prostatic resection (44). There were significant improvements in all primary outcomes in each group from randomization to followup. Transurethral prostatic resection was significantly better than laser therapy for I-PSS and maximum urinary flow values (p = 0.035 and 0.029, respectively) but there were no differences in post-void residual urine volume and I-PSS quality of life score between the groups. We noted significantly more treatment failures with laser therapy than resection (8 versus 0, p = 0.0014), although only 3 patients required resection after laser therapy because of persistent symptoms. In addition, hospital stay after resection was 2-fold that after laser therapy (ratio of geometric means 2.01, 95% confidence interval 1.54 to 2.61, p <0.0001). However, time to catheter removal was 9 times longer in the laser therapy group (p <0. 0001). Complication rates were significantly higher for transurethral prostatic resection (chi-square 5.05, 1 df, p = 0.025).

CONCLUSIONS

Transurethral prostatic resection is more effective than laser ablation in men with chronic urinary retention in terms of symptom score, maximum urinary flow and failure. However, men who underwent resection had significantly more treatment complications and were hospitalized longer than those who received laser therapy. This finding implies that laser ablation therapy may have a role in patients at higher risk who are willing to accept a lower level of effectiveness in exchange for decreased complication rates and hospital stay.

A randomized trial comparing transurethral resection of the prostate, laser therapy and conservative treatment of men with symptoms associated with benign prostatic enlargement: The CLasP study

PURPOSE

We evaluated the effectiveness of a new technology (noncontact laser therapy) versus that of standard surgery (transurethral prostatic resection) and conservative management for lower urinary tract symptoms associated with benign prostatic enlargement.

MATERIALS AND METHODS

Men with uncomplicated lower urinary tract symptoms, that is no acute or chronic urinary retention, were randomized to receive laser therapy with a noncontact, side firing neodymium:YAG probe, standard transurethral prostatic resection or conservative management, including monitoring without active intervention, in a large multicenter pragmatic randomized controlled trial called the CLasP study. Primary outcomes were International Prostate Symptom Score (I-PSS), maximum urinary flow rate, a composite measure of success based on I-PSS and maximum urinary flow rate categories, I-PSS quality of life score and post-void residual urine volume. Secondary outcomes included treatment failure, hospital stay and major complications. Followup was 7.5 months after randomization. Intent to treat analysis was done using analysis of covariance, proportional odds models and the Newman-Keuls multiple comparisons procedure.

RESULTS

Of symptomatic patients 117, 117 and 106 were randomized to receive laser therapy, transurethral prostatic resection and conservative management, respectively. Baseline characteristics were similar. All primary outcomes indicated that transurethral prostatic resection and laser therapy were superior to conservative management, and resection was superior to laser therapy. As measured by combined improved symptoms and maximum urinary flow, a successful outcome was achieved in 81%, 67% and 15% of men who underwent transurethral prostatic resection, laser therapy and conservative management, respectively. Hospital stay was significantly shorter and complications fewer for laser therapy than for resection but catheters were in place significantly longer. Men treated conservatively did not have deterioration or treatment failure.

CONCLUSIONS

Laser therapy and transurethral prostatic resection are effective for decreasing lower urinary tract symptoms and post-void residual urine volume as well as improving quality of life and maximum urinary flow in the short term in men presenting with moderate to severe symptoms. Transurethral prostatic resection is superior to laser therapy in terms of effectiveness but some patients may elect laser therapy due to the shorter hospital stay and lower risk of complications. Conservative management may be acceptable and safe in men with lower urinary tract symptoms since we observed no marked deterioration in the short term.

Undifferentiated leukemia following treatment of gastric cancer with 5 fluorouracil, doxorubicin, mitomycin C chemotherapy

Secondary leukemias are an increasingly well recognized complication of cancer chemotherapy. We report on the development of undifferentiated leukemia in a forty one year lady, eighteen months after treatment of gastric cancer with 5-fluorouracil (5 FU), doxorubicin and mitomycin C. She developed progressive weakness and pancytopenia over a period of few months. Leukemic blasts which were undifferentiated by immunophenotyping were seen in her peripheral blood. She died of intracranial haemorrhage during induction chemotherapy for the leukemia. Undifferentiated leukemia is a rare complication of FAM chemotherapy for gastric cancer.

Granular acute lymphoblastic leukemia with hypereosinophilic syndrome

A four-year-old boy presented with marked peripheral blood eosinophilia (absolute eosinophil count of 54 x 10(9)/1), features of hypereosinophilic syndrome, and acute lymphoblastic leukemia (ALL-L2), the latter characterized by the presence of granular blasts. Blasts were negative for myeloperoxidase, non-specific esterase, acid phosphatase, periodic-acid Schiff stain, and toluidine blue. They exhibited an early pre-B immunophenotype (TdT, CD19, CD10, CD20 and CD22 positive) and stained negative for T (CD7, CD2, CD5 and CD3) and myeloid markers (MPO, CD33 and CD13). Chromosomal analysis revealed a normal karyotype. To the best of our knowledge, this case represents the first report of the coexistence of granular ALL and hypereosinophilic syndrome.

Extramedullary myeloid cell tumor of the urinary bladder in a patient with myelodysplastic syndrome

We report a case of extramedullary myeloid cell tumor of the urinary bladder in an elderly male with a three year history of myelodysplastic syndrome (refractory anemia with excess blasts), noninvasive papillary transitional cell carcinoma of the urinary bladder, and in situ transitional cell carcinoma of the left ureter. Light microscopy demonstrated a poorly differentiated neoplasm composed of medium to large cells with eosinophilic cytoplasm. The tumor cells showed immunohistochemical expression of myeloperoxidase, lysozyme, CD15, CD68 and CD43. Bone marrow examination following cystectomy demonstrated refractory anemia with excess blasts (6-10%) and a normal karyotype. Cytogenetics, approximately 1 year after cystectomy, demonstrated a deletion of the short arm of chromosome number 12. Four years after presentation, the patient succumbed to pulmonary aspergillosis.

Extramedullary myeloid cell tumour: presentation as anterior chest wall mass during AML relapse

Acute myeloid leukaemia is an uncommon but an important cause of soft tissue swellings. Such extrameningeal, extramedullary leukaemic infiltrates are called extramedullary myeloid cell tumours. Despite their large size they may respond well to chemotherapy and local radiotherapy, as is demonstrated in this case.

Tuberculosis: a rare cause of splenic abscess

Splenic abscess is a rare condition associated with septicemic conditions. Splenic abscess due to tuberculosis is still rarer, mostly diagnosed in immuno-compromised hosts. A case of tubercular splenic abscess without any underlying disease is reported.

Fine needle aspiration of extramedullary myeloid cell tumor in myelodysplastic syndrome. A report of three cases

BACKGROUND

Soft tissue tumors are rare in myelodysplastic syndrome (MDS), and the role of fine needle aspiration (FNA) cytology in their diagnosis has not been explored.

CASES

Two patients with refractory anemia with excess blasts in transformation (RAEB-t) developed soft tissue swellings during the course of the illness. In a third patient, soft tissue swelling was a presenting feature. The swellings in all three cases were diagnosed as extramedullary myeloid cell tumor (EMT) on FNA and showed increased blasts (10-14%), dyspoietic changes, Auer rods and monocytosis.

CONCLUSION

Soft tissue tumors appearing in MDS are likely to be EMTs. FNA is therefore particularly valuable in their diagnosis as morphology, cytochemistry, immunophenotyping and flow cytometric analysis of hematopoietic cells are best studied on aspirated material. We suggest that FNA be preferred over excisional biopsy for the diagnosis of soft tissue swellings in MDS.

Suprapubic catheterization: a suitable procedure for clinical nurse specialists in selected patients

OBJECTIVE

To assess the feasibility and advantages of urology clinical nurse specialists (NSs) extending their professional role to include inserting initial suprapubic catheters in selected patients in the hospital and community setting.

PATIENTS AND METHODS

A urology NS, who is also the district continence adviser, was formally taught by a consultant urologist how to insert suprapubic catheters using the 'Add-a-Cath' introducer technique (Femcare, UK). Once deemed competent, the NS was indemnified by the Trust to carry out the procedure in carefully selected patients using a safe and unequivocal protocol.

RESULTS

Over a period of 40 months, the NS undertook the procedure in 164 patients, with 64 being catheterized in the community. There were no serious complications in the series and during the period studied, only 17 patients were referred back to the urologists for catheterization under formal theatre conditions.

CONCLUSION

Initial suprapubic catheterization can be carried out safely by trained NSs in selected patients. This extended professional role has helped to improve the continuity and quality of care for patients who require long-term catheterization. The NS was also a valuable source of training for junior medical staff who have limited experience with suprapubic catheterization.

Ocular extramedullary myeloid cell tumour in children: an Indian study

Thirty-two children with extramedullary myeloid cell tumour (EMT) who constituted 41 per cent of children with acute myeloid leukaemia (AML) were studied to ascertain their laboratory characteristics and potential problems in diagnosis. The diagnosis, established by peripheral blood smear and/or bone marrow examination, was AML (n = 29) and refractory anaemia with excess blasts in transformation (RAEB-t; n = 3). The six referred patients in whom the diagnosis had been missed, and two cases wrongly reported as histiocytosis on aspiration cytology, were those in whom a peripheral blood smear had not been examined. It is concluded that diagnostic work-up of proptosis must include a full haemogram, meticulous peripheral blood smear examination, repeated if necessary, and bone marrow examination where relevant. RAEB-t cases with extramedullary myeloid cell tumour should be classified as acute myeloid leukaemia.