Malignant Brenner tumour--a case report

Malignant Brenner tumour is a rare pathological entity. Apart from identification of typical benign, metaplastic and/or proliferating components, stromal invasion must be observed for diagnosis of Brenner tumour. A case of malignant Brenner tumour is described along with a brief review of strict criteria of diagnosis and its biological behaviour.

Emergency sclerotherapy for control of acute oesophageal variceal bleeding using 3% aqueous phenol: a 15‐year experience

BACKGROUND

The purpose of the present study was to compare the efficacy of emergency endoscopic variceal sclerotherapy (EVS) using 3% aqueous phenol as an initial procedure to control acute oesophageal variceal bleed.

METHODS

One hundred and ninety-five consecutive patients presenting with acute variceal bleed were included in the study. Protocol based endoscopic sclerotherapy and management of bleeding oesophageal varices was done. Immediate cessation of bleeding, re-bleeding within the first 72 h, success of first injection, final success of EVS, short-term mortality, influence of aetiology of portal hypertension and severity of liver disease on these results were studied.

RESULTS

Immediate cessation of bleeding was obtained in 191 out of 195 patients (97.9%). Twenty-seven (13.8%) patients re-bled within 72 h. On re-injection final success of EVS was 87.2% (170/195 patients). There was no significant difference between final success rate in cirrhotic versus non-cirrhotic patients (103/118 (87.3%) vs. 67/77 (87%)). Success of first sclerotherapy session was significantly higher than that of second sclerotherapy session. Surgical rescue was required in 25 (12.8%) patients. Mortality was 3.6%. Failure of EVS and mortality was significantly higher in Child's C group (P = 0.04, Relative risk = 0.5, confidence interval 0.22-1.16).

CONCLUSION

EVS remains an effective and cost effective modality of treatment to control acute variceal bleeding irrespective of aetiology of portal hypertension provided strict protocol based management is followed. With timely surgical rescue for the failures, the overall mortality can be reduced to less than 5%.

Pancreatoblastoma (infantile pancreatic carcinoma)--a case report

Pancreatoblastoma or infantile pancreatic carcinoma is a rare pancreatic tumor with distinct acinar and squamoid cell differentiation that generally affects infants and young children. Ultrasound and CT scan may be useful but preoperative diagnosis is often quite difficult. The outcome is generally favourable. A such case of 10 years old boy with an abdominal mass is being presented.

Thoracolumbar rachipagus parasite

A rare example of rachipagus conjoint parasitic twinning in a newborn girl is described. A lipomatous mass with an attached hind limb (with fused feet) and a rudimentary vertebral arch were found adherent to the dorsal vertebral arches of the autosite in the thoracolumbar region. There was a clear cleavage plane between the autosite and the parasite. Microscopic sections of the excised specimen showed gut only. The autosite had no other congenital anomalies except for spina bifida in the thoracolumbar region with unfolding of the underlying cord. In the absence of underlying life-threatening anomalies, surgical excision of the parasite and treatment of the associated anomalies of the autosite is known to offer gratifying results.

Gastric teratoma

Gastric teratoma accounts for less than 1% of all teratomas occurring in children, usually males. These tumors may be benign or malignant and complete excision of the tumor in either case carries a good prognosis. This rare case is an addition to the few cases of gastric teratomas in females reported in world literature and presenting as an exophytic & endophytic growth.

Significance of mucin stain in differentiating benign and malignant lesions of prostate

In an attempt to assess the significance of mucin stains in benign and malignant lesions of prostate, 200 prostatic biopsies in the department of Pathology, Pt. B.D. Sharma PGIMS, Rohtak were studied. All the biopsies were subjected to PAS and alcian blue staining along with H&E stain. Neutral mucin (PAS positive) was more frequently observed in benign prostatic lesions (93.3%) as compared to carcinoma (36%) while acid mucin (AB positive) was found more in carcinoma prostate (68%) as compared to benign prostatic lesions (16%). The positivity for acid mucin was more in well differentiating tumour decreasing significantly in high grade malignancies. With both types of mucin, luminal positivity was slightly more as compared to cytoplasmic positivity.

Splenic artery embolization for variceal hemorrhage following blocked distal splenorenal shunt

A blocked distal splenorenal shunt presents with torrential bleeding from gastric varices. Reoperation in the presence of portal hypertension in an unstable patient is difficult. Two patients with a blocked distal splenorenal shunt were subjected to splenic artery embolization. This stopped variceal bleeding from gastric varices resulting from the congested spleen due to thrombosis of the splenic vein. The procedure was successful in stopping the acute bleed in both patients. There were no serious complications or recurrent variceal bleeding and the varices were collapsed at one year on follow-up endoscopy. Splenic artery embolization is a safe and effective minimally invasive treatment for patients with bleeding from a blocked distal splenorenal shunt.

Extensive portal and splenic vein thrombosis: differences in hemodynamics and management

BACKGROUND/AIMS

To assess the incidence of extensive portal and splenic vein thrombosis in patients with extrahepatic portal vein obstruction and determine the differences in presentation, portal hemodynamics and management as compared to patients with portal vein thrombosis alone.

METHODOLOGY

118 patients of extrahepatic portal vein obstruction presenting with variceal hemorrhage, having received no definitive treatment prior to presentation were divided into two groups--with portal and splenic vein thrombosis and with portal vein thrombosis, based on ultrasonography and splenoportography. Collateralization patterns on splenoportography were studied. Results of endoscopic variceal sclerotherapy were compared.

RESULTS

Portal and splenic vein thrombosis was seen in 39 patients. Collateralization in case of portal and splenic vein thrombosis, in contrast to portal vein thrombosis, was predominantly left sided (74% vs. 9%, p < 0.0001). Fundal gastric varices were seen more often in patients with portal and splenic vein thrombosis (28% vs. 11%, p = 0.02), developing even after variceal obliteration, though obliteration was achieved in fewer sessions. Surgery for control of variceal bleed was performed more in the portal and splenic vein thrombosis group (33% vs. 15%, p = 0.02), especially for gastric varices (28% vs. 9%, p = 0.006).

CONCLUSIONS

Portal and splenic vein thrombosis is present in 33% of patients with extrahepatic portal vein obstruction. Hemodynamic patterns differ, accounting for the preponderance of gastric varices on presentation in patients with portal and splenic vein thrombosis and an increased need for surgery.

Hypophosphatemic rickets and osteomalacia in polyostotic fibrous dysplasia

A 17 year-old girl with polyostotic fibrous dysplasia and hypophosphatemia had inappropriately low tubular reabsorption of phosphate. She had radiological evidence of rickets and osteomalacia. The patient showed clinical improvement after treatment with phosphate supplementation, active vitamin D (calcitriol) and alendronate. It is postulated that either a phosphaturic substance elaborated from the dysplastic bone or target-organ (kidney) unresponsiveness may interfere with phosphate reabsorption in the renal tubule.

Giant cell reparative granuloma of the base of the skull presenting as a parapharyngeal mass

Giant cell reparative granuloma is an infrequent non-tumoral lesion affecting the maxillary and mandibular bones and only rarely, the cranial bones. We report a case of giant cell reparative granuloma of the base of the skull in a 12-year-old female who presented with a parapharyngeal mass. Computerized Tomography (CT) showed the intracranial extension and destruction of surrounding bones.

Maxillary mass as the presenting manifestation of papillary thyroid carcinoma

A case of follicular variant of papillary thyroid carcinoma presenting with a right maxillary mass is described. This is perhaps the first instance of maxillary metastasis from papillary thyroid carcinoma.

Congenital fibrolipoma of anal canal

Although rare, congenital lipomatosis presents during first few months of life as large sub-cutaneous fatty masses on chest with extension into skeletal muscle bundles. Only a few such cases have been reported in the literature. A rare case of congenital fibrolipoma of anal canal in a 3-day-old male child is being documented in the present report.

Primary malignant lymphoma of the breast

Primary malignant lymphomas of the breast (PBL) are uncommon constituting only 0.04 to 0.53% of malignant breast neoplasms. We wish to report the clinical, cytological and histologic findings of PBL diagnosed in a 52 years old female.

Significance of mucin secretion in carcinoma of uterine cervix

Biopsies from 300 cases with clinical diagnosis of carcinoma cervix were subjected to H&E staining, PAS with diastase and alcian blue at pH 2.5. Interpretation of cases on basis of H&E staining alone and on basis of H&E and mucin stains was done and results compared with each other. Categorization into squamous cell carcinoma (well, moderately & poorly differentiated), adenocarcinoma and mixed carcinoma was done. Morphologic assessment of cases of H&E stain revealed 282 (94%) cases of squamous cell carcinoma, 8 (2.66%) cases of adeno carcinoma and 10 (3.38%) cases of mixed carcinoma respectively. While on the basis of H&E and mucin stains, squamous cell carcinoma case turned out to be 266 (88.66%) in number; mixed carcinomas which included adenosquamous carcinoma and squamous cell carcinoma with mucin secretion accounted for 26 (8.66%) of cases, number of adenocarcinoma was unchanged i.e. 8 (2.66%). 16 of 282 cases (5.6%) diagnosed as squamous cell carcinoma on H&E stain alone were reclassified as mixed carcinoma on inclusion of mucin stains. Thus mucin stains are very helpful in deciding the types of carcinoma cervix and should be done in all cases of carcinoma cervix in order to avoid errors in diagnosis and to detect poorly differentiated mixed carcinomas, which may escape detection by H&E staining.

Pancreatoblastoma

Pancreatoblastoma is an extremely rare pancreatic tumor in childhood, comprising 0.5% of pancreatic non endocrine tumors. Just over 50 cases have been reported in the literature till 1997. A 10 year-old male child presented with mass abdomen of 9 months duration. USG and CT abdomen showed a large mixed density lobulated mass in abdomen anterior to, and displacing down the portal vein and splenic veins. Exploratory laparotomy revealed a large mass, arising from body and tail of pancreas, not infiltrating the adjacent structures. Complete excision of the mass along with removal of body and tail of pancreas was done. The histopathological examination revealed pancreatoblastoma. He is well without any evidence of disease 6 months after the operation. To the best of our knowledge this is the first case of pancreatoblastoma with a large size (25 x 20 x 15 cm,) weight 2.5 kg, which was localized and where complete excision was possible. The largest size reported in the literature reviews has been around 15 cm. The literature review confirms that an aggressive surgical attack on resectable pancreatoblastoma may often be curative. The role of adjuvant chemotherapy or radiotherapy is still under discussion due to small number of patients treated as yet.

Stress-specific activation and repression of heat shock factors 1 and 2

Vertebrate cells express a family of heat shock transcription factors (HSF1 to HSF4) that coordinate the inducible regulation of heat shock genes in response to diverse signals. HSF1 is potent and activated rapidly though transiently by heat shock, whereas HSF2 is a less active transcriptional regulator but can retain its DNA binding properties for extended periods. Consequently, the differential activation of HSF1 and HSF2 by various stresses may be critical for cells to survive repeated and diverse stress challenges and to provide a mechanism for more precise regulation of heat shock gene expression. Here we show, using a novel DNA binding and detection assay, that HSF1 and HSF2 are coactivated to different levels in response to a range of conditions that cause cell stress. Above a low basal activity of both HSFs, heat shock preferentially activates HSF1, whereas the amino acid analogue azetidine or the proteasome inhibitor MG132 coactivates both HSFs to different levels and hemin preferentially induces HSF2. Unexpectedly, we also found that heat shock has dramatic adverse effects on HSF2 that lead to its reversible inactivation coincident with relocalization from the nucleus. The reversible inactivation of HSF2 is specific to heat shock and does not occur with other stressors or in cells expressing high levels of heat shock proteins. These results reveal that HSF2 activity is negatively regulated by heat and suggest a role for heat shock proteins in the positive regulation of HSF2.

Angiogenic proteins in the lungs of children after cavopulmonary anastomosis

OBJECTIVE

Pulmonary arteriovenous malformations may cause progressive cyanosis after cavopulmonary anastomosis and may develop as a result of abnormal angiogenesis. We used immunohistochemistry to determine whether angiogenic proteins are increased in the lungs of children after cavopulmonary anastomosis.

METHODS

Lung specimens were obtained from 13 children after cavopulmonary anastomosis and from 6 control subjects. Specimens were stained with antibodies against vascular endothelial growth factor and its receptor (flk-1/KDR), basic fibroblast growth factor, alpha-smooth muscle actin, CD31, collagen IV, fibronectin, and proliferating cell nuclear antigen. Staining was graded on a scale of 0 to 3. Vessels positive for proliferating cell nuclear antigen were counted in 10 fields per specimen, and the results were averaged.

RESULTS

After cavopulmonary anastomosis, patients demonstrated increased staining for vascular endothelial growth factor (P =.03) and its receptor (P =.03) and decreased staining for CD31 (P =.004). Proliferating cell nuclear antigen staining in patients was equivalent to that for control subjects (P =.9).

CONCLUSIONS

Lung biopsy specimens from children after cavopulmonary anastomosis demonstrate increased expression of vascular endothelial growth factor and its receptor. These data confirm earlier findings that blood vessels forming after cavopulmonary anastomosis may have reduced intercellular junctions (decreased CD31 staining). Despite the increased numbers of pulmonary vessels that are present in these patients, these vessels are not highly proliferative (proliferating cell nuclear antigen staining equivalent to that of control subjects). These results suggest that vascular endothelial growth factor may be a mediator of angiogenesis in the lungs of children after cavopulmonary anastomosis; however, other factors, such as vascular dilation and remodeling, may also be important.

Pancreaticoduodenectomy for periampullary carcinoma

OBJECTIVES

To assess the morbidity, mortality and 1- and 2-year survival rates, and safety of pancreaticoduodenectomy for periampullary (including pancreatic head) carcinomas in a non-oncology surgical set-up.

METHODS

Records of 45 patients undergoing pancreaticoduodenectomies for periampullary cancers between July 1996 and April 2000 were reviewed. These included ampullary (n=23), pancreatic (14) and duodenal (2) adenocarcinomas, lower-end cholangiocarcinoma (5), and ampullary carcinoid (1). Thirty-seven patients underwent the Whipple procedure and 8 underwent the pylorus-preserving modification.

RESULTS

The overall mortality rate was 11% and morbidity rate was 46%. Wound infection was the most common postoperative complication. The 1- and 2-year survival rates for periampullary cancers were 61% and 39% and those for pancreatic cancers were 57% and 36%, respectively.

CONCLUSION

Pancreaticoduodenectomy for periampullary tumors remains a formidable procedure in our set-up. However, it can be performed safely with low mortality and morbidity rates.

Leiomyosarcoma of inferior vein cava presenting as acute Budd-Chiari syndrome

We report a 49-year-old lady who presented with acute Budd-Chiari syndrome. Spiral CT scan showed inferior vein cava (IVC) tumor and ischemia of the right liver secondary to hepatic vein blockage. These were confirmed by MRI scan and IVC gram, at which time tissue diagnosis was obtained. At surgery, the tumor was seen to originate from the infrahepatic IVC and extended to the level of the diaphragm, blocking the hepatic vein outflow. The tumor was excised completely. Histology confirmed it to be leiomyosarcoma of the IVC. The patient is well, without recurrence of symptoms or tumor, 10 months later.

Self-adhesive drape (Opsite) for management of leaking abdominal wounds

BACKGROUND

Leaking abdominal wounds (LAW) are associated with high patient morbidity.

OBJECTIVES

To evaluate the efficacy of a self-adhesive drape (Opsite) with suction drains for the management of LAW.

METHODS

Twenty patients with LAW (14 intestinal fistula, 4 biliary fistula, 2 ascites leak) were subjected to the use of a self-adhesive drape with a Romovac suction drain. Conventional wound management was used for the first 5 days, followed by the application of Opsite drape. The parameters evaluated were quantity of the effluent, skin integrity, ease of application, patient comfort and cost effectiveness. A discomfort score (based on four parameters: mobility, skin excoriation, wetness and unpleasant odor) was recorded on day 1 (pre conventional), day 5 (post conventional-pre Opsite), and day 5 after Opsite application. Opsite drape was changed whenever required.

RESULTS

The discomfort score was not altered with conventional therapy but was lower following Opsite application: mobility (0 vs 2), skin excoriation (0 vs 2), wetness (0.5 vs 2) and odor (0 vs 1). Opsite drape allowed accurate measurement of the effluent in all patients. The drape required change after a median of 14 days (range 10 to 18).

CONCLUSIONS

Opsite drape is easy to apply on LAW, is effective in containing the effluent, and is associated with low patient morbidity.

Gastric angina secondary to acute thrombosis of celiac artery

We report a 48-year-old woman with foregut ischemia with splenic infarct due to isolated celiac artery obstruction. The patient presented with acute-onset pain in the epigastrium 10-15 min after every meal. Investigations revealed obstruction of the celiac artery by artheromatous plaque. This patient had an acute thrombosis, which responded to anticoagulation.