Study of morphology with assessment of expression of proliferation marker Ki67 antigen and P53 protein in lesions of gall bladder

OBJECTIVE

To study the spectrum and distribution of histopathological changes and evaluate immunohistochemistry markers p53 protein and Ki67 antigen in various lesions of gall bladder.

MATERIALS AND METHODS

A total of 804 consecutive gall bladder specimens were evaluated. Forty cases were selected for immunohistochemical analysis to evaluate expression of p53 and ki67 proliferation index, including 20 carcinoma gall bladder cases and 20 cases of inflammatory pathology associated with metaplasia, atypia, hyperplasia, dysplasia, and adenoma. p53 immunostaining was categorized as wild type and mutant type. ki67 of >20% was considered high expression.

RESULTS

The majority of the gall bladder lesions were inflammatory in origin, most common being chronic cholecystitis. In the group of 20 gall bladder carcinoma cases, 65% were p53 mutant and the remaining 35% cases had a p53 wild-type immunophenotype. 55% cases showed high expression for ki67 labeling. However, significant correlation (P < 0.05) was seen with lympho-vascular invasion. Among non-malignant lesions, normal/wild-type p53 expression was seen with increasing intensity and positivity in lesions with atypia and intra-epithelial neoplasms. Ki67 index also showed the same trend in all cases.

CONCLUSIONS

p53 and ki-67 expression increases in inflammation, and further increment occurs in premalignant and malignant lesions of the gall bladder epithelium and can be used as a marker of aggression of histopathological lesions. The results emphasize the potential of Ki-67 and p53 as biomarkers of carcinogenesis in gall bladder carcinoma.

A retrospective clinicopathological analysis of rhino-orbital mucormycosis in second wave of COVID-19

Background

During the present surge of COVID-19 positive cases, concurrent multifold increase in the incidence of mucormycosis cases has resulted into significant morbidity and mortality. We retrospectively evaluated the clinicopathological features along with microbiological examination findings in histologically diagnosed cases of rhino-orbital mucormycosis.

Material and Methods

All the H and E and special stained slides of included mucormycosis cases were retrieved from the records and were evaluated with microbiological findings including screening KOH mount examination and culture results.

Results

Out of 16 cases with available details, 10 cases had the previous history of diabetes mellitus. The most frequent single site of involvement was maxillary sinus (7/25) followed by nasal cavity, orbit, ethmoid and sphenoid sinuses. While comparing the histological diagnosis with KOH mount findings and culture results, 15 cases revealed consistent results.

Conclusion

A high clinical suspicion, monitoring, early diagnosis, and timely management can improve the morbidity and mortality of this life-threatening complication.

Evaluation of variable p16 immunostaining patterns, Ki-67 indices and HPV status in cervical SILs and squamous cell carcinomas: An institutional experience

Objective

The present study evaluates the immunoexpression of p16 and Ki-67 in cervical squamous intraepithelial lesion (SIL) and carcinomas and correlates their expression with clinicopathological features and HPV-DNA status.

Material and Methods

A total 36 included cases of SIL and squamous cell carcinoma (SCC) were subjected to p16 and Ki-67 immunostaining. p16 staining was evaluated depending on grading, distribution, localization pattern, intensity and IHC score. Ki-67 expression was graded based on percentage of positive cells.

Results

Incidence of HSIL and SCC cases was found to be significantly increased with parity > 5. p16 grade III diffuse nucleocytoplasmic immunostaining was observed in 62.5% LSIL, 80% HSIL and 87% SCC cases. Significant association of p16 staining intensity, IHC score and Ki-67 indices was noted with increasing grades of SILs and carcinomas.

Conclusion

Our experience indicates that a combination of p16 and Ki-67 immunostaining may be useful to determine the severity of dysplastic change.

Immunoexpression of PTEN, HER2/neu, and Ki-67 in endoscopic gastric carcinoma biopsies; their correlation with histological subtypes and one-year survival

BACKGROUND

Gastric carcinoma is a major cause of cancer-related morbidity and mortality worldwide. Gastric neoplasms arise from genetic and epigenetic changes in various genes. Present study evaluates the immunoexpression of PTEN, HER2/neu, and Ki-67 in endoscopic gastric carcinoma biopsies and correlates the expression of these proteins with clinicopathological features.

MATERIAL AND METHODS

Adequate endoscopic biopsies of 27 cases of gastric carcinoma were evaluated for World Health Organization (WHO) and Lauren's classification subtypes along with HER2/neu, PTEN, and Ki-67 immunoexpression. HER2/neu immunostaining was scored as proposed in the Trastuzumab for gastric cancer (ToGA) trial while PTEN staining and downregulation were assessed using an immunoreactive score. The cut-off for Ki-67 expression was taken as 90^th percentile of the values in adjacent non-neoplastic tissue. All statistical analysis was done at 5% level of significance with SPSS v22 statistical software.

RESULTS

Tubular adenocarcinoma was the commonest WHO histological subtype and 56% of cases were of intestinal type as per Lauren's classification. 55.6% of cases showed a complete loss of PTEN expression in neoplastic tissue. 17 of the 19 cases with adjacent non-neoplastic tissue showed PTEN downregulation in neoplastic tissue. 81.5% of cases had a high Ki-67 index and HER2/neu overexpression was noted in 36% of cases. All the four cases who died had high Ki-67 proliferation indices; 3 patients had loss of PTEN expression and HER2/neu overexpression.

CONCLUSION

We conclude that these immunomarkers can play important role in the behavior of gastric carcinomas and can be targeted for new therapies.

Nasopharyngeal melanoma: An unusual entity

Nasopharyngeal melanoma is a rare condition with an estimated incidence of about 0.3/10 lac per year and has a slight female predominance. It can arise from stem melanocytes and mature melanocytes of the submucosa that have acquired genetic alterations, may be due to tobacco, trauma and oxidative stress. It resembles other common polypoidal lesions; therefore, histopathological examination with immunohistochemistry plays a pivotal role in confirming the diagnosis. Lack of specific clinical features often leads to a delay in diagnosis.

Epidemiological and clinical profile of Influenza A(H1N1) pdm09 in Odisha, eastern India

Epidemic of flu is highly contagious and it spreads through air. In 2009 H1N1 influenza virus emerged after reassortment of North American TRIG and Eurasia Avian like virus of swine and started epidemic in Mexico. The first cases were reported from Hyderabad city on 16th May 2009 in India that spread rapidly within a short span of time. During this period large population of Odisha situated at the eastern side of India was also affected and incidences of H1N1 cases were recorded through state Government surveillance system. In this study real time RT-PCR based diagnosis was conducted for the throat swabs collected from suspected H1N1 cases in Odisha during 2009–2017. A total of 2872 throat swabs were received from 23 different Government and private hospitals and 21.1% positivity was confirmed. The disease affected mostly 46–60 years age group, males (50.6%) being more affected. The clinical features had shown that fever with cough (89.6%) was the most common symptom followed by shortness of breath (72.7%). Post monsoon was the peak season in which most of the cases were reported. Neurological signs, pregnancy, diabetes and hypertension were found to be risk factors for H1N1. The case fatality rate (CFR) was 15%.

Molecular and phylogenetic analysis of the dengue strains circulating in Odisha, India

Dengue has emerged as a major public health challenge in terms of both changing clinical pattern and epidemiological features. The state of Odisha reported first dengue epidemic in the year 2010 and this continued each year in epidemic form during post monsoon period gradually becoming an endemic phenomenon. Present study depicts the changing epidemiological and clinical pattern of dengue with reference to its serotypes and genotypes. The study included 5320 suspected dengue cases from different health facilities of the state during 2010-2017. Dengue NS1 antigen and IgM antibody was done through ELISA. Serotyping was done through RTPCR by amplifying a part of core-pre-membrane gene (CprM) followed by sequencing and phylogenetic analysis. Dengue IgM antibody in 17.7% cases and NS1 antigen in 53.20% cases was detected. Dengue serotype 2 (DEN-2) was the only serotype detected in 2010 and 2011 where as all four serotypes 1, 2, 3, 4 were detected in 2012-2017, DEN-2 being dominant but in 2017 DEN-3 was found to be dominant. Phylogenetic analysis revealed genotype IV of DEN-2 and genotype III of DEN-1 and DEN-3 circulating in this region. In 6 cases involvement of DEN-2 in clinically evident encephalitis cases is an important observation in this region and needs public health attention. High prevalence of dengue was observed without any previous reported outbreaks in the state with increased number of cases from 2010 to 2012 affecting both urban and rural areas. High incidence in 2012 was due to co-circulation of more than one serotype which continued in the following years. Severity in some cases was associated with mixed infection but in most cases it was mild indicating the endemic nature of the virus in most parts of Odisha.

Cytopathology of Pulmonary Lesions: A Tertiary Care Center Experience

Background

Cytological evaluation of specimens from respiratory tract is the initial investigation in patients suspected to have pulmonary diseases. The various cytological specimens submitted for analysis include bronchoalveolar lavage, bronchial wash, brush smears, transbronchial needle aspiration, guided fine needle aspiration cytology (FNAC) smears and pleural fluid. Present study was undertaken to study the spectrum of lesions diagnosed by cytomorphological analysis of various cytological specimens.

Materials and Methods

Centrifuged and direct smears from received samples were stained with MGG and PAP stain. Special stains (ZN and PAS) were used wherever required. Cytohistological correlation was done wherever biopsy was available.

Results

This study included 671 samples from 583 patients suspected clinicoradiologically of having a respiratory pathology. A male preponderance (65.87%) was noted with 73.59% of patients in age group 40-80 years. Cytological diagnoses were classified as non-diagnostic (14.90%), negative for malignancy (59.76%), specific benign lesions (5.22%), positive for atypical cells (3.87%) and malignant (16.25%). Tuberculosis (TB) was found in 17 cases. Adenocarcinoma (both primary and metastatic) was the commonest malignancy of the 99 cases positive for malignancy. Incidence of primary lung adenocarcinoma and squamous cell carcinoma were found to be equal.

Conclusion

Lung carcinoma is presently the leading cause of cancer deaths while TB is still a common cause of death in developing countries. Cytopathology has a definite role in diagnosis of malignant lesions and also contributes in diagnosis of unsuspected chronic infections. Cytological diagnosis is fairly accurate if the specimen obtained is adequate and representative.

Role of p53 and Ki-67 immunomarkers in carcinoma of urinary bladder

BACKGROUND

Urothelial carcinoma is common urinary malignancy responsible for a significant proportion of cancer morbidity and mortality. We carried out the present study to demonstrate the clinicohistopathological features and to correlate the p53 and Ki-67 immunoexpression with grade and stage of bladder carcinomas.

MATERIALS AND METHODS

We investigated 110 cases of bladder tumor. Grading and staging were done according to the WHO-2004 and American Joint Committee on Cancer-TNM staging recommendations. Immunohistochemical staining for p53 and Ki-67 was performed in all the cases, categorized as high and low expression taking 20% positivity as cutoff value. Statistical analysis was done using McNemar's Chi-square test and Fisher's exact test.

RESULTS

There were 61 cases of high grade and 49 cases of low grade exhibiting urothelial carcinoma as the most common variant (97.3%). Muscle invasive carcinomas (pT2) noted in 29 cases whereas 23 and 58 cases revealed stage pTa and pT1, respectively. Evaluation of p53 and Ki-67 immunoexpression showed a significant association with histological grade and stage individually and also in combination (P < 0.05).

CONCLUSION

Our results corroborate with the opinion that combined use of p53 and Ki-67 immunomarkers may provide additional prognostic information along with histological grading and staging in bladder carcinomas.

Hepatic venous outflow tract obstruction: treatment outcomes and development of a new prognostic score

BACKGROUND

Results of endovascular interventions in hepatic venous outflow tract obstruction (HVOTO) have been reported from limited studies. Treatment outcomes and prognostic scores need further validation.

AIM

To evaluate treatment outcomes and prognostic scores for hepatic venous outflow tract obstruction in an Indian population.

METHODS

Consecutive patients with hepatic venous outflow tract obstruction diagnosed at a tertiary centre were included. Technical success and clinical response after endovascular interventional therapy were documented. Predictors of survival were assessed with Cox-proportional model. A new score was derived from the factors significant on multivariate analysis and compared with Child-Turcotte-Pugh, model for end-stage liver disease (MELD), Rotterdam prognostic index (PI) and Budd-Chiari syndrome-transjugular intrahepatic portosystemic shunt ( BCS-TIPSS) PI.

RESULTS

Three hundred and thirty-four patients (56.6% males), median age 24 (3-62) years were included. Hepatic vein was the commonest site of block-isolated hepatic vonous block in 48%, combined hepatic venous-inferior vena cava block in 46%. Endovascular interventional therapy was performed in 233/334 (70%) with 90% technical success. Clinical response was complete in 166 (71.2%), partial in 58 (24.9%) and no response in nine (3.9%). Majority of cases with HV block did not require TIPSS and could be treated with angioplasty (with/without stenting). On Cox-proportional multivariate analysis, Child class C and response to intervention were independent predictors of outcome and used to derive the All India Institute of Medical Sciences (AIIMS) hepatic venous outflow tract obstruction score. The 5-year survival was 92% (95% CI, 81-97%) for score ≤3, 79% (95%CI, 63-88%) for score >3 and ≤4, and 39% (95% CI, 21-57%) for score >4. The performance of AIIMS hepatic venous outflow obstruction score was superior to other prognostic indices.

CONCLUSIONS

Advanced Child class and no response to intervention are associated with poor outcomes. The All India Institute of Medical Sciences hepatic venous outflow tract obstruction score predicts survival better than other prognostic scores.

Scrotal chondroma in a young male: A rare case report

Soft tissue chondroma is a rare benign, slow growing tumor usually located in hand and foot. Scrotal chondroma is exceedingly rare; chondromas in the pelvic region have also been reported. However, chondroma occurring in the scrotal wall is extremely rare, and only a few cases have been reported worldwide. They should be differentiated from well-differentiated chondrosarcoma. To the best of our knowledge, this is the first case of scrotal chondroma to be reported from India.

GW627368X inhibits proliferation and induces apoptosis in cervical cancer by interfering with EP4/EGFR interactive signaling

PGE2, the major product of cyclooxygenases implicated in carcinogenesis, is significantly upregulated in cervical cancer. PGE2 via prostanoid receptor EP4 stimulates proliferation and motility while inhibiting apoptosis and immune surveillance. It promotes angiogenesis by stimulating the production of pro-angiogenic factors. The present study demonstrates GW627368X, a highly selective competitive EP4 antagonist, which hinders cervical cancer progression by inhibiting EP4/epithelial growth factor receptor (EGFR) interactive signaling. GW627368X reduced protein kinase A (PKA) phosphorylation which in turn leads to decreased cAMP response element-binding protein (CREB) activation. Decreased PKA phosphorylation also directly enhanced Bax activity and in part reduced glycogen synthase kinase 3 (GSK3)β phosphorylation. Owing to the interactive signaling between EP4 and EGFR, GW627368X lowered EGFR phosphorylation in turn reducing Akt, mitogen-activated protein kinase (MAPK) and GSK3β activity significantly. Sublethal dose of GW627368X was found to reduce the nuclear translocation of β-catenin in a time dependent manner along with time-dependent decrease in cytoplasmic as well as whole-cell β-catenin. Decreased CREB and β-catenin transcriptional activity restricts the aberrant transcription of key genes like EP4, cyclooxygenase (COX)-2, vascular endothelial growth factor and c-myc, which ultimately control cell survival, proliferation and angiogenesis. Reduced activity of EGFR resulted in enhanced expression of 15-hydroxyprostaglandin dehydrogenase increasing PGE2 degradation thereby blocking a positive feedback loop. In xenograft model, dose-dependent decrease in cancer proliferation was observed characterized by reduction in tumor mass and volume and a marked decrease in Ki67 expression. A diminished CD31 specific staining signified decreased tumor angiogenesis. Reduced expression of pAkt, pMAPK, pEGFR and COX-2 validated in vitro results. GW627368X therefore effectively inhibits tumor survival, motility, proliferation and angiogenesis by blocking EP4/EGFR interactive signaling. EP4 is a potent therapeutic target in cervical cancer and can be explored in combination with conventional therapies to attain superior outcomes and to overcome complications associated with organ toxicities, therapeutic resistance and disease relapse.

Adenoid cystic carcinoma in trachea: A rare presentation

Primary tracheal tumors are rare. Adenoid cystic carcinoma of trachea is even rarer. It occurs as a polypoidal mass in trachea presenting with dyspnea and respiratory distress due to tracheobronchial obstruction. We report a case of young male presenting with dyspnea for some time. CT scan revealed mass in trachea obliterating its lumen. Histopathological examination conirmed the diagnosis.

Primary MPNST in Childhood- A Rare Case Report

Malignant peripheral nerve sheath tumour usually occurs between 20-50 years of age, comprising about 5-10% of soft tissue sarcomas. Only 1.7% of them have been reported to occur in children < 5 months of age according to the literature. Here, we are describing 18 mnth old male child presented with a swelling in the lower back. MRI showed a sacrcoccygeal swelling extending to and communicating with CSF at lower sacral level. Birth history of the child was normal with normal apgar score. The histological diagnosis was malignant peripheral nerve sheath tumour. IHC showed focal positivity of GFAP and S100. Primary spinal MPNST in children are rarer. A careful neurological examination is warranted in children. Early diagnosis and referral to multidisciplinary team are important in ensuring the best diagnosis and optimal therapy in this young age.

Surgical Results of Non-small Cell Lung Cancer in Nepal

INTRODUCTION

Surgery remains the only curative modality for early stage of Non small cell lung caner (NSCLC). We reviewed overall scenario of lung cancer and surgical results in Nepal.

METHODS

1000 patients with the pathological diagnosis of lung cancer were analyzed to summarize the overall scenario of lung cancer. 157 NSCLC patients underwent pulmonary resection. cIA, IB, IIA, IIB, IIIA (N1) underwent surgery as initial modality of treatment. cIIIA (N2) patients were taken for surgery after neoadjuvant chemo/ chemoradiation.

RESULTS

Analysis of 1000 patients showed squamous cell carcinoma in 41.3%, incurable stage (IIIB/ IV) in 66.8% and rate of curative resection in 6.7% cases. Surgery as a single modality of treatment was used in 38%. Neoadjuvant Chemo/ chemoradiation/ radiation followed by surgery and surgery followed by chemo/ chemoradiation/ radiation was done in 12% and 50%, respectively. In-hospital mortality was 2% (post pneumonectomy: 5.5%; post lobectomy: 1.5%; post sublobar resection: 0%). R0 resction was achieved in 91% cases. Median survival and 5-year overall survival were 36 months and 18%, respectively. Better survival was achieved in pI-II vs pIII/ IV, pN0-1 vs pN2 and pR0 vs pR+ (p <0.05).

CONCLUSIONS

Earlier stage (pI-II), R0 resection and pathological pNo-1 has the best five year overall survival in Nepalese patients with NSCLC as well.

Histopathological study of placentae in low birth weight babies in India

Background:

The antenatal health-care given to pregnant women has great influence on the rates of perinatal death and morbidity. Amongst the different causes of perinatal mortality, low birth weight (LBW) is the single most significant factor therefore placenta from all the LBW babies (LBWB) should be examined routinely to find out the likely cause.

Aims:

The aims of this study were to assess the pathological changes in the placenta in association with LBWB.

Materials and Methods:

This is a Case control study performed at Medical College Allahabad,(MLN) India. In this study, 90 placentae were included. 30 placentae from full-term vaginally delivered babies, weighing more than 2500 g were included as the control group. 60 placentae belonged to babies whose birth weight was less than 2500 g (LBW). Weight of the baby was taken within the 1^st h of birth and Apgar score was noted. Gross and microscopic examination of placentae was done. Statistical correlation of was carried out between them by using SPSS 18 version. Chi-square test with or without yate's correction was used as and when required. P < 0.05 was taken as critical level of significance.

Results:

Placenta was circum-marginal in both groups. Attachment of cord was mainly central in the control group 90% (27/30), whereas eccentric attachment was prominent in patient group 66.67% (40/60). The difference was statistically significant (P < 0.001). Calcification and sub-chorionic fibrin deposition was seen in significantly higher numbers of placentae from patients than controls (P < 0.01) infarction and meconium staining were seen in placentae from patients only. Histologically placental ischemia, infarction and calcification were seen in significantly higher number of patients (P < 0.001, P < 0.001 and < 0.01 respectively). Fibrinoid necrosis, stromal fibrosis, placental dysmaturity and obstructive vasculopathy were seen in placentae from patients only.

Conclusion:

Placental pathology among LBW infants was high in comparison to control group. The findings suggest that chronic ischemia and associated secondary changes probably lead to improper perfusion and LBWB.

Diffuse intestinal submucosal lipomatosis with incidental epidermal inclusion cyst of caecum clinically masquerading as carcinoma caecum

Symptomatic diffuse submucosal intestinal lipomatosis is a rare entity. Also few cases of epidermal inclusion cyst of caecum have been reported in literature. Here, we are presenting a rare case of intestinal submucosal lipomatosis with coincidence of epidermal inclusion cyst of caecum and presumptively diagnosed as carcinoma of ileocaecal region during surgery in a 55 years old male. Both are rare entity considering the location even they should be kept as a differential diagnosis in unusual cases of intestinal perforations with inconclusive radiological findings or clinical uncertainity.

Polymeric nanoparticle formulation of octapeptide (NP-OP): in vitro release and in vivo effect in common marmosets, Callithrix jacchus Linn

Octapeptide (OP)/FSH-Receptor Binding Inhibitor-8 (FRBI-8), is a synthetic peptide corresponding to N-terminal sequence of purified fraction of Follicle Stimulating Hormone Binding-Inhibitor (FSHBI), isolated earlier from human ovarian follicular-fluid. In order to avoid the repeated drug-administration, OP-loaded, polymeric polylactide (PLA) nanoparticle formulation (NP-OP), was developed using multiple-emulsion technique. This yielded an average particle size of 120 nm with 70% encapsulation-efficiency. In vitro release profile of NP-OP showed sustained release of OP for 21 days. In vivo anti-fertility studies were conducted in marmosets. Results indicated that control animals conceived in the same cycle while two of three treated animals failed to conceive in treatment cycle. The in vivo studies thus corroborate with in vitro release of OP, demonstrating its anti-fertility activity in 66% of animals.

A comparative study of clinical profiles of vivax and falciparum malaria in children at a tertiary care centre in uttarakhand

BACKGROUND

Falciparum malaria has been constantly associated with high morbidity and mortality for a long time. Vivax malaria, which was once thought to be a relatively benign condition, is appearing in its more malignant form, with severity gradually becoming a serious concern.

AIM

This study is aimed to find out and compare the clinical and pathological manifestations of vivax and falciparum malaria in pediatric age group in Uttarakhand.

SETTING AND DESIGN

A prospective study was carried out at a tertiary care hospital of a medical college in Uttarakhand, India.

MATERIAL AND METHODS

This study was done for a period of 2 years, from December 2010 to November 2012. Patients of 18 years age or below from Uttarakhand and nearby regions, who were smear positive or antigen positive were included in the study.

STATISTICAL ANALYSIS

p value was calculated using Pearson Chi-square with Yates correction by DAG stat software.

RESULT

Eighty Five patients were found to be suffering from malaria. 61 (71.8%) had vivax malaria, while 24 (28.2%) patients suffered from falciparum. Larger majority of malaria patients in both the groups happened to be males. The detailed study of morbidity profile clearly establishes that the complication related severity, earlier attributed to only falciparum is equally seen in vivax. Thrombocytopenia was the commonest finding in both. Other complications seen in both groups were those of cerebral malaria, severe anemia, ARDS, renal failure, malarial hepatitis, leucocytopenia, pancytopenia, shock with multiorgan dysfunction and hemoglobinuria. Even the mortality in the two groups was of the same order as p value calculated for the difference between the two species was well above 0.05.

CONCLUSION

Vivax malaria is an important cause of mortality and morbidity. The severity of illness is almost similar in both vivax and falciparum malaria.

Granulocytic sarcoma presenting as an orbital mass: report of two cases

Granulocytic sarcoma is a rare variant of a myeloid malignancy, which shows an extra-medullary tumour mass which is composed of myeloblasts and myeloid precursors with varying degrees of differentiation. It occurs most commonly in bone, periosteum, soft tissue, lymph nodes, and skin; although it can occur anywhere throughout the body. Here, we are reporting two cases of orbital granulocytic sarcoma in children, which presented clinically with proptosis and periorbital swellings, which were first diagnosed by Fine Needle Aspiration Cytology (FNAC). Later, peripheral blood and bone marrow aspirate examinations revealed the evidence of Acute Myeloid Leukaemia (AML). These cases are being documented to demonstrate the utility and diagnostic accuracy of FNAC in evaluation of this entity, in cases of unsuspected AML. Recognition of this rare entity is important, because giving an early aggressive chemotherapy can cause regression of the tumour and thus improve the patient survival.

Endodermal sinus tumor of vagina in infants

Endodermal sinus tumor (or Yolk Sac tumor) of the vagina is a rare malignant germcell tumor which is seen exclusively in children younger than 3 years of age. We report two cases of endodermal sinus tumor of the vagina. In both cases no radiological investigation was done and serum alpha-fetoprotein was elevated. The histopathological examination of both the tumor masses revealed vaginal endodermal sinus tumor. Periodic-acid-Schiff stain with diastase showed diastase resistant hyaline globules. These findings confirmed the diagnosis of endodermal sinus tumor in both cases. Vaginal endodermal sinus tumor is both locally aggressive and capable of metastasis. The serum alpha-fetoprotein level is a useful marker for diagnosis and monitoring the recurrence of vaginal endodermal sinus tumor in infants. Early detection and therapy is important because of its aggressive nature and good response to chemotherapy.

Myoepithelioma breast: clinically masquerading as breast carcinoma

Pure myoepithelioma of breast is an extremely rare tumor. Only a few cases have been reported in the literature so far. A 30-year old female presented with a large fungating mass arising from the areolar region of her right breast of six months duration. A clinical diagnosis of breast carcinoma was made and a mastectomy was performed. The specimen measured 23×22×9 cm with attached skin, and showed a large white ulcerated growth with areas of necrosis and hemorrhage. No normal breast tissue, nipple or areolar region was seen. Histopathological examination showed oval to spindle cells arranged in fascicles and bundles with whorling pattern in places showing mild pleomorphism with oval to spindle-shaped vesicular nuclei, prominent eosinophilic nucleoli, eosinophilic cytoplasm and clear cell changes in places, along with perivascular hyalinization and collagenization. Differential diagnosis of pleomorphic hyalinizing angiectatic tumor, solitary fibrous tumor, perivascular epithelioid cell tumor, mammary type myofibroblastic tumor and myoepithelioma were all considered. Immunohistochemistry for vimentin, smooth muscle actin, calponin, caldesmon, p63, epithelial membrane antigen, S-100, CD-31, CD-34, muscle specific antigen, myogenin, desmin, and pancytokeratin was carried out. On the basis of positive staining for vimentin, actin, p63 (nuclear), calponin and caldesmon (focal), a final diagnosis of myoepithelioma was considered; however, cytokeratin negativity was an unusual finding. This case was considered worthy of documentation because of its rarity, and because it highlights the importance of proper clinical examination and radiological examination to prevent misdiagnosis.

Transnasal trans-sphenoidal endoscopic repair of CSF leak secondary to invasive pituitary tumours using a nasoseptal flap

Cerebrospinal fluid (CSF) leak following initiation of Dopamine agonist therapy for macroprolactinomas, although uncommon, has been described previously in the literature. Traditional management includes primary repair of the defect using either fat or fascia lata in conjunction with lumbar drain insertion. In this case series we outline two cases of CSF leak secondary to invasive pituitary tumour that were repaired successfully using a nasoseptal flap. We believe that this form of repair is effective and associated with minimal morbidity.

Eight-year experience in esophageal cancer surgery

AIM

Esophageal cancer remains a major and lethal health problem. In Nepal, not much has been explored about its management. The aim of this study was to conduct a retrospective review of esophageal cancer patients undergoing surgery or combined modality treatment at a cancer hospital in Nepal.

MATERIALS AND METHODS

Resectable cases were treated primarily with surgery. Locally advanced cases with doubtful or obviously unresectability underwent preoperative chemo/radiation or chemoradiation followed by surgery.

RESULTS

Among 900 patients, 103 were treated with curative intent. Mean age of patients was 54 years, and 100% of the patients presented with complaint of dysphagia. Surgery as a single modality of treatment was done in 57% of cases, and the remaining underwent combined modality treatment. Transthoracic and transhiatal approaches were used in 95% and 5% of cases, respectively. Nodal sampling, two-field (2-FD), and three-field lymphadenectomy (3-FD) were done in 18%, 59%, and 20% of cases, respectively. A majority of patients had pathological stage III disease (46.6%). In-hospitality mortality was 5%, and anastomotic leakage rate was 14%. In 87% of patients, R0 resection was achieved. Overall, 4-year survival was 20%. A R0 resection, early-stage disease and 3-FD favored the survival advantage (P < 0.05).

CONCLUSION

The mortality, complication, and survival results were in the acceptable range. R0 resection and radical nodal dissection should be standard practice.

Giant Cell Tumor Arising from Anterior Arc of First Rib- A Rare Presentation

We report a case of Giant Cell Tumor (GCT) arising from anterior are of first rib along with literature review which was treated with excision of rib through its normal margin along with tumor mass. GCT of rib is rare and if found mostly arises from the posterior aspect. However, GCT should be considered as differential diagnosis when bony mass is present in the anterior are of rib. It poses surgical challenge for excision because of the delicate and vital neurovascular structures passing above it between clavicle and first rib. Keywords: first rib, giant cell tumor.

Giant cell tumor arising from anterior arc of first rib: a rare presentation

We report a case of Giant Cell Tumor (GCT) arising from anterior are of first rib along with literature review which was treated with excision of rib through its normal margin along with tumor mass. GCT of rib is rare and if found mostly arises from the posterior aspect. However, GCT should be considered as differential diagnosis when bony mass is present in the anterior are of rib. It poses surgical challenge for excision because of the delicate and vital neurovascular structures passing above it between clavicle and first rib.

Use of greater omentum in thoracic onco-surgery

BACKGROUND

Omentum is well known for its immunocompetence and good blood supply; and therefore, is being used in various complex thoracic procedures. Specially, in situations when staplers, sealants and total parenteral nutrition may not be used because of financial constraints, omentum may prove very helpful in preventing post-operative fatal complications.

METHODS

A retrospective review of 61 patients was undertaken. Patients were categorized into two groups. In group I, omentum was sutured to the anastomosis for prophylaxis of leak from gastro-oesophagectomy after radical surgery for cancer of cardia and oesophagus. In group II, it was used for therapeutic purpose, to control diffuse air leak from lung parenchyma after chest wall and invaded lung resection for malignant chest wall tumours (subgroup A) and treatment of post pneumonectomy bronchopleural fistula for NSCLC of right lung (subgroup B). Gastro-oesophagectomy, closure of bronchial stump and suturing of lung parenchyma after wedge resection was done with manual suturing technique only.

RESULTS

Group I: There were 57 patients with the diagnosis of cancer of cardia and oesophagus, who underwent radical surgery. Transthoracic approach was used in 96.5% patients, whereas 3.5% patients underwent transhiatal resection. Anastomotic level was located in chest in 68.4% and in neck in 31.6% patients. The leakage rate was 5.4%. Group II: There were three patients in subgroup A, all with lesions located in left side of chest wall. There was one patient in subgroup B. Chest tube was removed after a mean time of 2 days and after 4 days in subgroup A and B, respectively. There was 1 mortality (1.6%) secondary to chylothorax.

CONCLUSION

Use of pedicled omentum appears to be a very simple technique to prevent the anastomotic leak after radical surgery for cancer of cardia and oesophagus, and to seal the diffuse parenchymal pulmonary leak after various procedures in thorax.

Clinical study of sentinel lymph node biopsy in early uterine cervical carcinoma

BACKGROUND

Radical hysterectomy and complete pelvic lymphadenectomy is the standard treatment for early cervical carcinoma. But the rate of pelvic and paraaortic nodal metastasis is found to be low, pointing that most of the patients possibly undergo unnecessary nodal dissection.

AIM

To study the value of sentinel lymph nodes (SLNs) in prediction of the pelvic lymph node status and to determine the significance of SLN detection in pelvic lymph node dissection in patients with early stage cervical carcinoma.

SETTINGS AND DESIGN

Retrospective study.

METHODS

From August 2002 to August 2004, 20 patients with early stage cervical carcinoma, planned to undergo radical hysterectomy and extensive pelvic lymph node dissection received an intracervical injection of a blue dye to identify and perform resection of SLN. The SLNs were pathologically compared with non-SLNs with frozen section, paraffin section, and anti-cytokeratin immunohistochemical staining.

RESULTS

Out of 20 patients, SLNs were detected in 15 patients. A total of 46 SLNs were identified and the mean was 3 per patient. The detection rate of SLN was 75%. Sensitivity, specificity and accuracy of the SLN biopsy were 75%, 100% and 95%, respectively.

CONCLUSION

SLN detection can predict the pelvic lymph node status in early stage cervical carcinoma, but the feasibility and safety of this technique to substitute conventional surgical modality should be evaluated by large series of prospective studies.

How we performed chest wall reconstruction: analysis 31 cases

OBJECTIVE

To see the results of patients who underwent chest wall resection and reconstruction (CWRR).

SETTING AND DESIGN

Retrospective descriptional study.

MATERIAL AND METHODS

We retrospectively reviewed all patients who underwent CWRR at Xingtai People's Hospital in China and B.P. Koirala Memorial Cancer Hospital in Nepal. A total of 31 patients were reviewed. Among them, 20 were male and 11 female. The median age was 63 years. The indications for resection were primary chest wall tumor in 21 patients (67.7%), lung cancer with invasion of chest wall 6 (19.4%), recurrence of breast cancer 2(6.3%), radiation necrosis 1(3.2%) and skin cancer 1(3.2%).

RESULTS

The mean number of rib resected was 3.6 ribs, which induced a mean defect of 97.1 cm2. Concomitant resection was done in 13 patients, including lung resection 10, partial resection of diaphragm 2, and partial sternectomy 1. Seven patients underwent soft tissue reconstruction (STR) alone and 5 patients skeletal reconstruction (SR) alone. Simultaneous SR and STR were performed in 19 patients. Three patients (9.7%) developed postoperative complications. The median survival period was 22 months.

CONCLUSION

Primary chest wall tumor and lung cancer invading chest wall are the most common diseases indicating CWRR. Simultaneous bony and soft tissue reconstruction was reliable for chest wall reconstruction in most cases and prevents postoperative complications.

The Ayurvedic medicines Haritaki, Amala and Bahira reduce cholesterol-induced atherosclerosis in rabbits

Four groups of 25 rabbits each, were studied to determine the effect of Haritaki (Terminalia chebula), Amla (Emblica officinalis) and Bahira (Terminalia belerica) on cholesterol-induced hypercholesteolaemia and atherosclerosis. The control group was fed with cholesterol alone; the Haritaki group received Haritaki and cholesterol; the Bahira group received Bahira and cholesterol; and the Amla group received Amla and cholesterol for 16 weeks. Cholesterolaemia was significantly less (P less than 0.001) in the Haritaki group (166 mg/dl), the Bahira group (240 mg/dl) and the Amla group (205 mg/dl) than in the control group (630 mg/dl). The Haritaki group had significantly less cholesterolaemia (P less than 0.001) as compared to the Bahira and Amla groups. Aortic sudanophilia was significantly less (P less than 0.001) in the Haritaki group (6%), the Bahira group (16%), and the Amla group (12%) than in the control group (38%). The cholesterol contents of the liver and aorta, respectively, were significantly less in the Haritaki group (46 mg/100 g, 28 mg/100 g), the Bahira group (78 mg/100 g, 72 mg/100 g) and the Amla group (46 mg/100 g, 42 mg/100 g), than in the control group (604 mg/100 g, 116 mg/100 g). Among the drug-fed groups, the Haritaki group had significantly lower degrees of sudanophilia and cholesterol content of aorta and liver (P less than 0.001) as compared to the Bahira and Amla groups. Although all three drugs reduced serum cholesterol, aortic sudanophilia and cholesterol contents of liver and aorta, their effects were in ascending order of magnitude. The drugs did not influence serum triglyceride levels, euglobulin clot lysis time or platelet adhesiveness.(ABSTRACT TRUNCATED AT 250 WORDS)

A rare case of Castleman's disease presenting as a pulmonary mass mimicking pulmonary malignancy

Castleman disease is a rare disorder of the lymphoid system characterized by noncancerous growths that may develop in lymph node tissues throughout the body. Most often this occurs in the neck, mediastinum, and abdomen where lymph nodes aggregate. The etiology is thought to be due to antigenic hyperstimulation of unknown origin. Two histological subtypes are described with different clinical presentations and therapeutic implications. Diagnosis is frequently accomplished only by histological analysis after surgery since no specific features have been found in imaging studies. Surgical excision is both diagnostic and curative in localized forms, whereas additional therapies are required in multicentric forms. Here we describe a case of castleman disease adjacent to the right pulmonary hilum loosely adherent to the interlobar branch of the right pulmonary artery that mimicked tuberculosis or malignancy in a 30-year-old man who underwent curative surgical removal of the mass. Keywords: Castleman disease; Pulmonary malignancy; IL-6; HHV-8; Kaposi sarcoma DOI: 10.3126/jpn.v1i1.4456 Journal of Pathology of Nepal (2011) Vol.1, 63-65