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   2015| March-April  | Volume 4 | Issue 2  
    Online since March 9, 2015

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Acute lymphoblastic leukemia presenting with a uterine cervical mass
N Geetha, VS Lali, Anitha Mathews, NP Prakash
March-April 2015, 4(2):280-281
Involvement of female genital tract with acute lymphoblastic leukemia (ALL) is extremely rare, and it is even rarer for a patient to have symptomatic presentation. We report the case of a middle-aged lady with ALL, who presented with severe abnormal uterine bleeding and a uterine cervical mass. Biopsy of the cervical mass showed infiltration by leukemic blasts. She received chemotherapy with Berlin-Frankfurt-Munster protocol and is alive in remission after 10 years.
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Is multiparity a protective mechanism in Iraqi females with breast cancer? Need for detailed analysis
Vivek Tiwari, Subodh C Pande, Kamal Verma, Sandeep Goel
March-April 2015, 4(2):292-293
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Hypofractionated versus conventional radiotherapy with or without chemotherapy in head and neck cancer: A comparative study
Somnath Roy, Chandrani Mallik, Suman Ghorai, Avijit Hazra, Anup Majumdar
March-April 2015, 4(2):140-146
Background: To investigate tumor response and toxicities in head and neck squamous cell cancer (HNSCC) upon hypofractionated radiotherapy compared with conventional fractionation. Settings and Design: Data from patients with squamous cell cancer of oral cavity, oropharynx, hypopharynx, and larynx (AJCC, 2010 Stage II to IVB); who received hypofractionated (n = 30) or conventionally fractionated (n = 30) radiotherapy, with or without chemotherapy, between January 2010 to June 2011 were retrieved and retrospectively analyzed. Materials and Methods: In conventional arm (Arm A), each patient received 70 Gy at 2 Gy per fraction over 7 weeks, along with concurrent cisplatin (100 mg/m 2 ) on days 1, 22, and 43 for locally advanced stage. In hypofractionated arm (Arm B), each patient received 55 Gy at 2.75 Gy per fraction over 4 weeks, along with concurrent cisplatin (100 mg/m 2 ) on days 1 and 22 for locally advanced stage. The end points were tumor response, acute and late toxicities, overall survival (OS), and diseases-free survival (DFS). Results: The tumor response distribution was comparable - 24 (80%) patients in arm A and 23 (76%) in arm B achieved a complete response. Significant differences in frequencies of acute grade ≥ 2 skin toxicity, mucositis were found, with higher frequencies in Arm B. Higher frequencies of late grade ≥ 2 dysphagia, laryngeal edema, xerostomia, and confluent mucositis were encountered in Arm B at 6 months from start of chemoradiation. However, OS, DFS, and loco-regional recurrence rates were comparable between the two arms. Conclusions: Hypofractionated radiotherapy can achieve similar tumor response to conventionally fractionated radiotherapy in HNSCC, although with some increase of toxicity.
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Clinicopathologic significance of Papanicolaou smear study of postmenopausal women in a rural tertiary care center
Ambedkar Raj Kulandai Velu, Banushree C Srinivasamurthy, M Balamurugan
March-April 2015, 4(2):147-151
Background: Cervical cancer is a preventable disease in the vast majority of women. Papanicolaou (Pap) smear is still the most effective screening tool available for preventing cervical cancer. Therefore, it is important to investigate the significance of screening in older women. Objective: To study the distribution of cervical cancer among postmenopausal women and to determine the significance of cervical cancer screening in symptomatic and asymptomatic postmenopausal women. Materials and Methods: A total of 590 Pap smears were obtained from postmenopausal women between September 2012 and March 2013. Prefixed conventional cervical smears were stained with Pap stain. The cytology results were reported using the Bethesda system terminology. Results: Among the 590 postmenopausal women studied, 38.9% of asymptomatic postmenopausal women had clinically significant lesion whereas only 33.1% of symptomatic women had clinically significant lesion. There was low-grade squamous intraepithelial lesion at percentage of 17.5. Asymptomatic and symptomatic were 11.5% and 6.5%, respectively. High-grade squamous intraepithelial lesion was 4.5%. Asymptomatic and symptomatic were 7.5% and 2.85%, respectively. Atypical squamous cells of undetermined significance were seen in 8.85%. Asymptomatic and symptomatic were 4.25% and 4.6% respectively. Atypical glandular cells of undetermined significance were 1.7%. Only 3.2% of significant lesion was squamous cell carcinoma, and all were symptomatic. Conclusion: Postmenopausal women especially from the rural area and low socioeconomic strata suffered disproportionately from precancerous and cancerous lesions of the cervix. To reduce this burden, it's mandatory to motivate and screen asymptomatic older women.
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Challenges in the management of cancer pain in elderly population: A review
Akhil Kapoor, Ashok Kalwar, Mukesh Kumar Singhal, Raj Kumar Nirban, Harvindra Singh Kumar
March-April 2015, 4(2):111-119
Elderly people are more susceptible to the experience of pain than any other sector of the population. Neoplasia is an important cause of pain in the elderly population. The prevalence of persistent pain in older persons living in a care home setting is estimated at 45-80%, thus highlighting that persistent pain in older people is widespread and problematic in these settings. This article reviews the difficulties in the management of pain in the elderly population and the important differences from other population besides describing the various pain assessment tools, pharmacologic and nondrug management of pain.
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Early diagnosis and prompt therapy can save one's eye
Prakas Kumar Mandal, Tuphan Kanti Dolai
March-April 2015, 4(2):243-245
Myeloid sarcoma (MS) also known as granulocytic sarcoma or chloroma, is a rare extramedullary tumor of immature myeloid cells. MS is reported in 2.5-9.1% of patients with acute myeloid leukemia (AML) and occurs concomitantly, following or rarely, antedating the onset of systemic bone marrow leukemia. Orbital involvement by acute MS is relatively rare. However, in the setting of simultaneous bilateral orbital tumors in children, MS appears to be a highly likely, if not the most likely, diagnostic possibility. Any child with an orbital mass of uncertain origin, particularly if it is a bilateral, should undergo prompt evaluation for underlying AML. Early diagnosis and prompt therapy can save one's eyes.
  1 1,823 26
Posterior reversible encephalopathy syndrome in non-Hodgkin's lymphoma: Not necessarily reversible!
Akhil Kapoor, Vanita Kumar, Surender Beniwal, Samrat Dutta, Shekhar Goyal, Harvindra Singh Kumar
March-April 2015, 4(2):226-229
Posterior reversible encephalopathy syndrome (PRES) is a rare clinicoradiological entity that is an increasingly recognized complication of pediatric cancer treatment. However, there have been very few reports of PRES in association with non- Hodgkin's lymphoma (NHL) and reported incidence is only 0.06%. The available literature and case reports on PRES were studied in depth, and the important conclusions were taken into account for writing athe review. We describe a case of PRES in a boy of 15 years with NHL on cyclophosphamide, doxorubicin, vincristine and prednisolone combination chemotherapy who presented with generalized seizures and reversible blindness. Magnetic resonance imaging of the brain revealed characteristic findings of the syndrome establishing the diagnosis. However, despite transient improvement of the symptoms, the patient succumbed to respiratory failure. The authors conclude that PRES is a rare entity especially in NHL patients that must be recognized early and should be managed aggressively as it may prove to be fatal also.
  1 2,396 25
Neurofibromatosis with chronic myeloid leukemia in an elderly male: An unusual association
Satya Narayan, Akhil Kapoor, Narender Kumar, Mukesh Kumar Singhal, Neeti Sharma, Ankur Patel, Surender Beniwal
March-April 2015, 4(2):266-267
Neurofibromatosis is a genetic disorder of neural crest-derived cells that predominantly affect growth and development of neural tissues. We report a case of 64-year-old patient, had several soft tissue cutaneous nodules (neurofibroma) on the body including the face, head, and neck, extremities and multiple hyperpigmented macules on trunk and back (Café-au-lait pigmentation), who was accidentally diagnosed as chronic myeloid leukemia, on routine investigation for surgical management. He did not have any systemic manifestation either of diseases.
  1 1,322 23
Targeting the programmed cell death 1 pathway: A new approach to the treatment of advanced melanoma
Puneet Kumar Bagri, Saurabh Samdariya, Puneet Pareek, Zoya Rizwan
March-April 2015, 4(2):290-291
  1 1,398 27
Comparison of the efficacy of the palpation versus ultrasonography-guided fine-needle aspiration cytology in the diagnosis of salivary gland lesions
Nazoora Khan, Nishat Afroz, Swati Agarwal, Mohammad Amanullah Khan, Ibne Ahmad, Hena A Ansari, Sunanda Chauhan, Divya Rabindranath, Azka Anees Khan
March-April 2015, 4(2):134-139
Background: Fine-needle aspiration cytology (FNAC) is the initial investigation for salivary gland swellings. The aim of this study was to study the utility of ultrasonography (USG) as an adjunct to cytology in the diagnosis of salivary gland lesions and to compare the two methods, palpation-guided and ultrasound-guided FNAC in diagnosis of salivary gland lesions. Materials and Methods: The study comprised of 45 patients presenting with a salivary gland swelling. All the patients were subjected to USG examination and FNA of the swellings-both by palpation method and ultrasound guided, in each case. Further, the cytological features of all the cases were studied comparing the findings on palpation-guided versus USG-guided FNAC. Histopathological correlation was also done wherever possible. Results: Number of inadequate aspirations decreased and the number of lesions detected increased on using USG-guided FNAC. Only two cases were false negative on USG-guided FNAC, and there were no false positive cases. While on palpation-guided FNAC, three cases came out to be false negatives, and one was seen to be false positive. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive values were higher for USG-guided FNAC than for palpation-guided FNAC. Conclusion: We concluded that though differentiation of salivary gland masses was difficult on USG alone due to nonspecific USG findings, combination of ultrasound with FNAC certainly improved the diagnostic efficiency. USG guidance led to more representative, meticulous sampling which helped in providing a correct diagnosis in the majority of cases.
  1 1,850 20
Molecular analysis of the rearranged during transfection proto-oncogene in Moroccan patients with medullary thyroid carcinoma
Abdessamad El Annas, Hinde Iraqi, Nabila Fritez, Mohammed El Mzibri, Youssef Bakri, Abdelmjid Chraibi, Latifa Hilal
March-April 2015, 4(2):188-198
Background: Germline mutations of the proto-oncogene rearranged during transfection (RET) are pathognomonic of hereditary medullary thyroid carcinoma (MTC). In this study, genetic analysis and familial testing of the RET proto-oncogene in Moroccan families with MTC were performed. Patients and Methods: Thirty-one index cases with MTC and 115 of their relatives were included in this study. The entire coding region of RET was investigated by direct sequencing of polymerase chain reaction products. Once a mutation was identified, the target exon was sequenced in available relatives. Results: Seven distinct germline mutations of RET were identified in 45.2% (14/31) of probands. The most prevalent mutations were located at codon 634 (p.C634R/Y/F) and restricted to families with multiple endocrine neoplasia type 2A (MEN2A) (50% of the 14 mutation carriers, 7/14), followed by mutation at codon 918 (p.M918T) in all MEN2B cases (21.4%, 3/14), then by mutations at codons 804 (p.V804L/M) (14.3%, 2/14); and 891 (p.S891A) (14.3%, 2/14) detected in all patients with apparently sporadic MTC. Familial screening detected RET mutations in 19.1% (22/115) of the studied relatives; 36.4% (8/22) were found with MEN2A symptoms, and 63.6% (14/22) were asymptomatic. About 55% (12/22) were subjected to total therapeutic or prophylactic thyroidectomy. Conclusion: This is the first comprehensive genetic screening showing the spectrum of mutations in RET in Moroccan patients with MTC, which showed a predominance of mutations at codon 634. These results further support the necessity of genetic testing in MTC patients to provide early diagnosis and adequate initial treatment of these patients. This will moreover, contribute to the definition of a national policy for the control of this cancer in Morocco.
  1 1,919 32
Investigation the role of human cytomegalovirus in the invasive ductal breast carcinoma
Ahmed Hasan Mohammed, Haider Sabah Kadhim, Alaa Hussein Ghani
March-April 2015, 4(2):199-205
Background: Breast cancer is the most common type of female malignancy. Increasing evidence in the last 10 years suggests that human cytomegalovirus (HCMV) is associated with several human malignancies including breast cancer. This study aimed to investigate HCMV in invasive ductal breast carcinoma by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry (IHC). Materials and Methods: A total of 50 samples of the cancer mass and non-neoplastic safe margin (SM) tissues of breast cancer collected then processed for paraffin block to apply IHC and hematoxylin-eosin staining. In addition to that, 30 blood samples collected from patients and healthy women (controls) for detection of anticytomegalovirus (antiCMV) IgG and IgM by ELISA. Results: About 38 samples (76%) of 50 samples diagnosed as invasive ductal carcinoma (IDC). The results showed that the presence of antiCMV antibody IgG in 100% of patients while the IgM presented in 76.7% of patients. There were significant differences (P < 0.05) between the optical densities of the IgG in breast cancer patients when compared healthy women. The positive results of CMV protein comprise 34 (89.4%) for immediate early 1 (IE1) protein, 35 (92.1%) for late protein, and 34 (89.4%) for phosphoprotein 65 (pp65) from 38 sample of IDC. The results also showed the absence of expression to CMV late and pp65 proteins and low percentage (10%) of IE1 protein in the SM tissues. Conclusion: Many studies including our observation indicated to the association of HCMV with breast cancer, but the role of HCMV in the pathogenesis of breast cancer is unclear.
  1 1,980 24
Analysis of bone metastasis in head and neck squamous cell carcinoma: Experience of a regional cancer center
Akhil Kapoor, Ashok Kalwar, Satya Narayan, Narender Kumar, Mukesh Kumar Singhal, Harvindra Singh Kumar
March-April 2015, 4(2):206-210
Background: Bone metastasis is a rare occurrence in head and neck squamous cell carcinoma (HNSCC). This retrospective study was performed to analyze the frequency and patterns of skeletal metastasis in HNSCC. Materials and Methods : We analyzed records of 8326 HNSCC patients attending our oncology outpatient department from January 2000 to December 2013. All statistical calculations were performed using MedCalc software for windows, version 12.5.0 (Osterd, Belgium). Results : Bone metastasis was found in 25 patients (0.3% of total HNSCC patients, nasopharynx excluded). 10 patients (0.66%) of carcinoma tonsil had skeletal metastasis. The patients of younger age groups had higher frequency of bone metastasis; 1.56% patients of age group 20-29 years while 0.26% patients of 60-69 years age group had skeletal metastasis (P < 0.001). However, no patient of >70 years age was found to have bone metastasis. Most common site of metastasis was spine (56%) followed by pelvis (32%). Isolated involvement of a single bony site was present in 64% of the metastatic cases. Conclusion: Bone metastasis though very rare, should be considered for evaluation in patients of HNSCC especially in younger patients.
  1 4,544 26
Interleukin-6 and interleukin-4 levels in multiple myeloma and correlation of interleukin-6 with β2 microglobulin and serum creatinine
Usha Singh, Chhaya Rani Shevra, Shailja Singh, Niladri Singh, Sandip Kumar, Madhukar Rai
March-April 2015, 4(2):211-215
Background: Multiple myeloma (MM) is a very common hematological malignancy in elderly person throughout the world. Cytokine network have been implicated in the pathogenesis of MM especially in bony lesions, which are the predominant features of plasma cell dyscrasia. Aims and Methods: The aim of this study was to investigate level of serum interleukin 6 (IL-6) and its correlation with β2 microglobulin and serum creatinine and level of IL-4 in MM. Both cytokines and β2 microglobulin were estimated by ELISA kit. Results: Serum IL-6 level was done in 34 patients of MM and 75 healthy controls. It was found to be elevated (>11 pg/ml) in 69.7% cases, whereas none of the control cases had this value. There was no correlation of serum IL-6 with age of the patient, serum β2 microglobulin or serum calcium but serum IL-6 correlated positively with serum creatinine. Rise of IL-6 in MM as compared to control was highly significant. Contrary to this serum IL-4 level in 60% MM cases were below 2.5 pg/ml and rest 40% patients had it between 2.5 and 12 pg/ml. Contrary to this, 86.67% healthy control had IL-4 between 2.5 and 12 pg/ml and only 13.33% had its value below 2.5 pg/ml. Statistically reduction of IL-4 when compared to control was significant. Conclusions: Our study concludes that MM is associated with increase in IL-6 and decrease in IL-4 in majority cases. In future, treatment with monoclonal antibody to IL-6 and recombinant IL-4 can be used to treat the patients of MM.
  1 2,157 26
Fibroadenoma in male breast: Case report and review
Sunder Goyal, Snigdha Goyal, Aseem Trikha
March-April 2015, 4(2):220-222
Fibroadenoma is very common in females, but rare in male breast. Gynecomastia and/or lobular differentiation have been known to coexist in both types of fibroepithelial lesion in men. We report a young adult having gynecomastia associated with fibroadenoma.
  - 10,374 21
Mucinous Cystadenocarcinoma of Ovary in Preadolescence: An Ordinary Tumor but at an Unexpected Age
Jitendra Kumar Nangal, Satya Narayan, Akhil Kapoor, Ramesh Purohit, Harvindra Singh Kumar
March-April 2015, 4(2):223-225
Malignant epithelial ovarian tumors are common in adult women, but are rare in childhood. Especially, mucinous ovarian cystadenocarcinoma are extremely rare in pediatric age group, only a limited number of cases are reported in this age group till date with no case reported in preadolescence age in the literature. We describe a case of mucinous cystadenocarcinoma in eleven year old premenarchal girl presenting with symptoms of abdominal distension and respiratory distress from last three months.
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Nonfunctioning paraganglioma of the urinary bladder: A rare entity
Veena Gupta, Jyoti Sharma, Ashok Sangwaiya, Vaanika Kaira, Swagatika Samal, Rajeev Sen
March-April 2015, 4(2):268-270
Paraganglioma of the urinary bladder is a rare tumor accounting for ˂0.06% of all bladder tumors and ˂1% of all pheochromocytomas. The distinction of paragangliomas from urothelial carcinoma is likely to be critical because of differences in therapeutic management. We report a case of 24-year-old female who presented with a complaint of intermittent hematuria and no other characteristic symptoms of paraganglioma. Ultrasonography revealed a lobulated mass arising from the anterior wall of the urinary bladder. Imaging studies and other relevant investigations were inconclusive. Transurethral resection was done and sent for histopathology. On histopathology, final diagnosis of paraganglioma was made. Patient is symptom-free postoperatively and is on regular follow-up 6 monthly.
  - 1,324 27
Pure primary squamous cell carcinoma of breast: A rare entity
Mohammed Akram, Samreen Zaheer, Shahid A Siddiqui, Rana K Sherwani
March-April 2015, 4(2):271-273
Squamous cell carcinoma (SCC) of the breast is very rare malignancy, and only few cases have been reported in the literature. Also, it is aggressive in nature, and the standard treatment is still debated. We share our experience of a case of primary SCC of breast which was initially misdiagnosed as adenocarcinoma on fine needle aspiration cytology but later confirmed to be pure primary squamous cell carcinoma of breast on histopathological examination.
  - 1,575 22
Sarcomatoid carcinoma of the gallbladder: A case report and review of the literature
Yasmeen Khatib, Datta Prasanna Kulkarni, Richa D Patel, Asha Bankapur
March-April 2015, 4(2):274-276
Sarcomatoid carcinoma of the gallbladder is a rare variant of undifferentiated carcinoma composed of both malignant epithelial and mesenchymal components. Preoperative differentiation of this tumor from adenocarcinoma is difficult because of its overlapping clinical and radiological features. However, the prognosis of this tumor is poor with a median survival of only 5.5 months. Surgical resection is the treatment choice for these tumors, but chances of recurrence are high. To our knowledge, 80 cases of sarcomatoid carcinoma of the gallbladder have been reported in the world literature. We report a case of sarcomatoid carcinoma of the gallbladder in a 65-year-old male who was treated with a radical cholecystectomy with extrahepatic bile duct resection. A hepaticojejunostomy with Roux en Y jejunojejunostomy and regional lymphadenectomy was done. A Ro resection was achieved in this case. We report this case because of its rarity, difficulty in its specific preoperative diagnosis and to emphasize the need of immunohistochemistry to confirm the diagnosis.
  - 1,828 22
Anaplastic cerebral hemangiopericytoma: Rare variant of a rare disease
Purnima Thakur, Mukesh Sharma, Manish Gupta, Debajyoti Chatterjee, Vikas Fotedar
March-April 2015, 4(2):277-279
Intracranial hemangiopericytoma (HPC) is a rare tumor of central nervous system, anaplastic type (grade 3) being the rarest. HPC closely mimics meningiomas in clinical and radiological features, thus, its diagnosis and treatment is a challenge. We report a rare case of histopathologically diagnosed anaplastic HPC of frontal lobe of the brain. A lady in her 60's presented with neurological signs of impaired memory, headache, decreased vision and slurring of speech that gradually progressed to aphasia over a period of 2 months. A space occupying lesion was identified on magnetic resonance imaging in the left frontal region. Left frontal craniotomy and Simpson grade 1 excision of the tumor was done. Postoperative radiotherapy was administered in view of positive margins on histopathological specimen. We describe the clinical, radiological, and histological features of this tumor, its outcome on completion of treatment and on subsequent follow-up along with a review of the literature.
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Low-grade adenosquamous carcinoma breast in 55-years-old female: A diagnostic challenge
Shilpa Garg, Shivani Kalhan, Neha Garg, Shweta Rana, Manmeet Kaur Gill, Ashok Sangwaiya
March-April 2015, 4(2):230-232
Low-grade adenosquamous (LGAS) carcinoma is rare morphological variant of metaplastic breast carcinoma. Only few cases have been reported in the literature so far. We reported a case of LGAS carcinoma in 55-years-old female who presented with huge lump breast since 6 months. On fine needle aspiration cytology, it was diagnosed as mesenchymal tumor with uncertain malignant potential. Mastectomy without axillary clearance was performed. On histopathology diagnosis of LGAS carcinoma was made and patient was kept on regular follow-up. Due to limited literature available LGAS carcinomas are usually misdiagnosed and treated as benign breast lesions. These tumors have risk of local recurrence after incomplete excision and low metastatic potential also. So, high index of suspicion should always be kept for these tumors to diagnose them at early stage.
  - 1,444 25
Recurrent epithelioid sarcoma of wrist: A case report and review of literature
Puneet Kumar Bagri, Akhil Kapoor, Amit Kumar Sharma, Mukesh Kumar Singhal, Shankar Lal Jakhar, Harvindra Singh Kumar
March-April 2015, 4(2):233-236
Epithelioid sarcoma is a rare variety of soft tissue sarcoma that affects young adults mostly involves forearm and hand. It mainly presents as a painless slow growing mass, but can present as multifocal lesions. It has a high rate of recurrence and metastasis. A 35-year-old male presented to our department in November 2013 with a painful ulcer with bloody discharge in the medial side of left wrist. The patient gave a history of swelling with serous discharge from 11 years. Local excision was done 6 times from 2003 to 2011. The patient also gave a history of falling on an outstretched hand and swelling at same site in July 2013, this time again wide local excision was done. The histopathology report was suggestive of high-grade osteogenic sarcoma. Immunohistochemistry (IHC) showed expression of cytokeratin, epithelial membrane antigen, CD34 and CA-125; tumor cells had lost INI-1 expression. IHC confirmed the diagnosis of epithelioid sarcoma of left wrist. Contrast-enhanced computed tomography thorax was suggestive of lung metastasis. Thus, doxorubicin based chemotherapy was planned.
  - 2,214 22
Renal cell carcinoma manifests primarily as endobronchial mass: An unusual presentation
Rina Mukherjee, Jayeeta Banerjee, Madhumita Mondal, Debjit Banerjee
March-April 2015, 4(2):237-239
Endobronchial metastasis (EBM) from renal cell carcinoma (RCC) is a very rare entity, though pulmonary metastasis of RCC is common. Here, we present a case of RCC with EBM, in which the primary tumor was detected after the detection of secondary. A 60-year-old man presented with cough for last 2 months. Contrast enhanced computed tomography (CECT) chest followed by bronchoscopy revealed an endobronchial mass at left bronhi. CECT whole abdomen revealed a left-sided renal space occupying lesion (SOL). CT guided fine needle aspiration cytology of the SOL proved it as a RCC. Palliative bronchoscopic removal of endobronchial mass by snaring diathermy was done.
  - 1,323 23
Pleomorphic adenoma of the palate in an edentate male patient: An unusual clinical presentation
Suresh Kumar Sachdeva, Pradhuman Verma, S Sunderraj, Manoj Vengal
March-April 2015, 4(2):240-242
Pleomorphic adenoma of palate in an edentate patient is a rare entity. Accurate clinical examination, imaging modalities and histopathological examination are needed for early diagnosis and management. The late diagnosis may result in difficulty in speech and swallow, problems in denture fabrication, resorption of bone and may result in complicated treatment procedures. Here, we discuss the case of the edentulous patient with undiagnosed palatal swelling, causing difficulty in denture fabrication. A multidisciplinary approach should always be followed involving oral and maxillofacial physician, radiologist, surgeon and prosthodontist in managing such palatal pathology.
  - 1,270 24
Conjunctival-corneal intraepithelial neoplasia: Presenting as a pterygium
Mohammad Banyameen Iqbal, Iqra Mushtaq, Atul Jain, Spriha Arun
March-April 2015, 4(2):246-248
Ocular surface squamous neoplasia (OSSN) comprises a wide spectrum of dysplastic alterations of the squamous epithelium of the surface of the eye, for example, the cornea and the conjunctiva ranging from "precancerous" lesions to bona fide invasive carcinoma. The epithelial infiltration can range from mild to severe dysplasia (i.e. mild, moderate, or severe corneal intraepithelial neoplasia) to full thickness epithelial dysplasia. We are presenting a case of a 55-year-old male patient who presented with a sudden increase in the size of her pterygium for the last 3 months, which were finally diagnosed to be carcinoma in situ.
  - 2,018 24
Verrucous carcinoma arising in the setting of postnephrectomy sinus
Ashima Batra, Nisha Marwah, Rajnish Kalra, Meenu Gill, Sanjay Marwah, Rajeev Sen
March-April 2015, 4(2):249-251
Marjolin's ulcers are malignancies that arise in chronic venous ulcers, scars, burns, long-standing wounds or sinuses. The most common type of carcinoma arising in the Marjolin's ulcer is squamous cell carcinoma (SCC), followed by basal cell carcinoma. Verrucous SCC (VSCC) comprises about 3% of all SCCs. It is most commonly diagnosed in the oral cavity, and the incidence is approximately one in a million/year. To the best of our knowledge, malignancy arising in a postnephrectomy sinus has never been described before. We herein report a case of VSCC in a sinus developed after nephrectomy done for renal stones.
  - 1,175 22
A case of bronchial/lung carcinoid cytological, histological and immunohistochemical corroboration
Sarita Asotra, Sudershan Sharma, Vijay Kaushal
March-April 2015, 4(2):252-254
Lung carcinoids tumors are uncommon tumors that start in the lung. They tend to grow slower than other types of lung cancers. Carcinoids tumors start from cells of the diffuse neuroendocrine system. It is widely recognized that cytology is superior to small biopsy in diagnosing small cell lung carcinoma since the crush artefacts limiting small biopsy interpretation is minimized in cytology. Similarly, carcinoids can be accurately diagnosed in cytology and small biopsy specimen. A correct preoperative cytological diagnosis helps in planning early and optimal surgery. We received the fine-needle aspiration cytology sample of bronchial mass of 46-year-old patient presenting with cough and hemoptysis for 2 months. Diagnosis of carcinoid tumor was given on cytology that was confirmed on histopathology and immunohistochemistry.
  - 1,403 22
Lung cancer presented as hydro-pneumothorax: A rare radiological masquerade
Ritam Chakraborty, Surajit Chatterjee, Rajat Subhra Saha, Arnab Sit
March-April 2015, 4(2):255-257
Herein, we report a case of lung cancer presented initially as hydro-pneumothorax and has undergone intercostal tube drainage, received repeated courses of antibiotics and even antitubercular drugs without any improvement. Without a confirmatory diagnosis, patient was referred to our institution. Based on initial and follow-up chest X-rays, it was suspected to be either an encysted empyema or lung abscess. But on computed tomography (CT) thorax the thick walled cavitary mass was seen, and CT guided fine- needle aspiration cytology proved the diagnosis. Thus, it's a rare presentation of lung cancer as hydro-pneumothorax.
  - 2,930 25
Conventional renal cell carcinoma with granulomatous reaction: A rare entity
Reetika Sharma, Vijay Kaushal
March-April 2015, 4(2):258-259
Granulomas may develop in a number of immunologically mediated infectious and noninfectious conditions. Granulomas may also occur within the malignancies like carcinomas of the breast, colon, and Hodgkin's lymphoma. Granulomatous reaction in association with renal cell carcinoma (RCC) is uncommon, with only fewer published reports in the literature. We reported a case of a conventional (clear cell) RCC associated with epithelioid granulomas within the tumor parenchyma.
  - 1,467 28
Primary splenic lymphoma masquerading as splenic abscess: A rare case
Debdas Bose, Senjuti Dasgupta, Nirmal Kumar Bhattacharyya, Pranab Kumar Biswas
March-April 2015, 4(2):260-262
The incidence of primary splenic lymphoma (PSL) is <1%. Here we report a case of PSL in a 63-year-old female patient who had fever, night sweats, anorexia, and weight loss for 2 months. Abdominal contrast-enhanced computed tomography showed mild splenomegaly with multiple patchily enhancing splenic space occupying lesions (SOLs) along with multiple enlarged splenic hilar lymph nodes. A provisional diagnosis of splenic abscesses was made. Following splenectomy, histopathological examination and immunohistochemical analysis revealed this to be a case of splenic non-Hodgkin lymphoma - diffuse large B-cell - nongerminal center type. This case is significant since it was misdiagnosed as splenic abscess initially. Even though, PSL is an extremely rare tumor, this entity must be borne in mind when splenic SOL is detected radiologically. Documentation of such rare cases is of utmost importance to facilitate early diagnosis and treatment of similar cases in the future.
  - 1,858 20
Cytodiagnosis of calvarial metastasis of renal cell carcinoma masquerading as a cavernous hemangioma after a long latency
Yasmeen Khatib, Erbaz Momin, Richa D Patel, Anuja Kamat
March-April 2015, 4(2):263-265
Renal cell carcinoma (RCC) is noted for its unpredictable clinical behavior. It can present with metastatic disease at many unusual sites, even after a long latency. It can thus mimic many other lesions and pose a diagnostic challenge, especially in cases where prior history of RCC is not available. Fine-needle aspiration cytology (FNAC) can be very useful in arriving at a correct diagnosis of these lesions. We present an unusual case of RCC in a 55-year-old female who presented with frontal soft tissue mass. A history of nephrectomy 10 years back was not given at the initial presentation. Computed tomography suggested a diagnosis of cavernous hemangiomas. FNAC was suggestive of RCC. Avascular osteolytic lesion in the calvarium should raise the suspicion of metastatic RCC as one of the differential diagnosis.
  - 1,288 23
Hodgkin's lymphoma of the breast: A rare occurrence
Rina Mukherjee, Madhumita Mondal, Debjit Banerjee, Mahadeb Mukherjee
March-April 2015, 4(2):282-285
Breast lymphoma is a rare condition, and both as a primary and a metastatic manifestation. The primary form has an incidence ranging from 0.04% to 0.5% of all breast neoplasms, whereas the metastatic form has an incidence of 0.07%. Hodgkin's lymphoma of the breast is a very rare entity both as primary and as well as secondary. Hereby, we report a case of 57-year-old lady presented with a left-sided breast lump with axillary lymphadenopathy. Fine-needle aspiration cytology and histopathological study revealed features of Hodgkin's lymphoma. Fluorodeoxyglucose positron emission tomography scan showed neoplastic lesions at left breast, axilla, thigh, pelvis and inguinal region. She presented with cervical lymphadenopathy, 4 years back, diagnosed as Hodgkin's lymphoma for which she received 12 cycles of chemotherapy followed by thoracic field radiotherapy. Now the patient is further on chemotherapy for recurrence and is being followed-up.
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Monophasic synovial sarcoma of the tongue in an elderly lady: A diagnostic dilemma
Sharmila Dudani, Ajay Malik, Kavita Sahai, Madhurjya Barman
March-April 2015, 4(2):286-288
Synovial sarcoma (SS) is a morphologically characteristic sarcoma of uncertain lineage, typically containing both epithelial and mesenchymal elements. The most common location is the extremities, and very few cases have been reported from the head and neck region. The monophasic spindle cell variant often poses a diagnostic challenge as it mimics poorly differentiated carcinoma or sarcoma. We report a case of monophasic SS of tongue in a 74-year-old female. On Immunohistochemistry, the tumor cells showed strong, diffuse positivity for vimentin, Bcl-2, CD99, and focal positivity for epithelial membrane antigen. Tumor cells were negative for pan cytokeratin, smooth muscle actin, S100, HMB-45, CD34. A high index of clinical suscipicion is required to reach an accurate diagnosis for institution of appropriate therapy.
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Metachronous second primary of sigmoid colon presenting as an atypical extraluminal pedunculated polypoidal fluorodeoxyglucose-positron emission tomography-computed tomography incidentaloma
Sandip Basu, Abhishek Mahajan
March-April 2015, 4(2):289-290
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Gastrointestinal stromal tumors: Indian perspective
Rashmi Patnayak, Venkatarami Reddy, Sriram Parthasarathy, Amitabh Jena, Mandyam Kumaraswamy Reddy
March-April 2015, 4(2):293-293
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Do we need to spare central nervous system structures during head and neck cancer intensity modulated radiotherapy?
Trinanjan Basu, Tejinder Kataria, Shikha Goyal, Deepak Gupta, Kuldeep Sharma
March-April 2015, 4(2):216-219
Introduction: Fatigue has always been a distressing symptom for patients of head and neck cancer (HNC) on radiotherapy. Although modern technologies like intensity modulated radiotherapy (IMRT) have been instrumental in reducing many of the distressing side-effects but the recent observation of increased fatigue has been a concern. Recent publications though very few hinted at possible correlation with dosage to central nervous system (CNS) structures. The current resource review highlights a very preliminary example of a futuristic approach. Materials and Methods: This retrospective analysis comprising of 20 HNC patients receiving either postoperative or radical radiotherapy by IMRT were evaluated with CNS dosage. The main organs contoured in planning computed tomography (CT) scan were brainstem (BS) and posterior fossa (PF) excluding BS. The dose received to these organs was recorded. The literature reported CNS structure dosage, which can probably cause increased fatigue was assessed. Results: Among the 20 nonnasopharyngeal HNC, 13 received radical radiotherapy and 7 had postoperative radiotherapy. Six patients had treatment gap varying between 2 and 10 days, mostly due to hematological toxicities and oral mucositis. The median volumes of PF and BS were 263.5 and 25.1 cc. Dmax for BS and PF ranged between 4.8 and 44.76 Gy and 23.8-63.2 Gy and the median Dmean for PF was 8.89 Gy. Conclusion: Future prospective analysis with inclusion of modified brief fatigue inventory scale and dosimetric evaluation of CNS structures would probably answer the necessity of sparing CNS structures and spare patients from excessive fatigue and related consequences.
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Cytological evaluation of enlarged lymph nodes in metastatic disease: A hospital-based assessment
Ghazala Mehdi, Amit Kumar Singh, Mahboob Hasan, Hena A Ansari, Suhailur Rehman, Sadaf Mirza, Rana K Sherwani
March-April 2015, 4(2):152-157
Background: Lymphadenopathy is a heterogeneous entity with many underlying causes, ranging from self-limiting benign disease to severe neoplastic proliferations. Fine-needle aspiration is a cost-effective and reliable tool for initial investigation of enlarged lymph nodes. Materials and Methods: A study was conducted on 326 patients with metastatic disease in order to evaluate the efficacy of cytology in diagnosing malignancies metastatizing to the lymph node and predicting their primary origin as well as to find the relative frequency of different malignancies. The findings were also correlated with histopathology. Results: Cervical lymph nodes were the most frequently involved group, followed by axillary, supraclavicular, and inguinal lymph nodes. Squamous cell carcinoma (SCC) and adenocarcinoma were the most common cytological diagnosis. Among the cases with known primary tumors, head and neck was the most common site followed by breast carcinoma. Most common lymph node group to be aspirated in cases with unknown primary was cervical lymph node, and SCC was most frequently diagnosed cases. Sensitivity and positive predictive value of cytological diagnosis were calculated to be 100% and 93.1%, respectively. Conclusion: Fine-needle aspiration cytology has a very high sensitivity and positive predictive value and hence, a presumptive diagnosis can be made along with the detection of the primary site in case of metastatic disease.
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Low dose rate caesium-137 implant time of intracavitary brachytherapy source of a selected oncology center in Ghana
John Owusu Banahene, Emmanuel Ofori Darko, Baffour Awuah
March-April 2015, 4(2):158-164
Background: The treatment time taken for a radioactive source is found to be very important in intracavitary brachytherapy treatment. The duration of the treatment time depends on the prescribed dose requested to a reference point and the calculated dose rate to the same point. The duration of the treatment time of source is found to depend on the tumour stage. In this work, the treatment time of implant has been calculated for a Caesium-137 low dose rate brachytherapy source at an oncology facility in Ghana. Objective: The objective was to determine how the treatment time of tumours depends on the dose rate to the reference point prescribed by the Oncologists and the dose rate determined by the dosimetrists at the facility. Materials and Method: Depending upon the stage of the cancer, the Oncologist determines the type of treatment modality, source configuration for the cancer patient and positions of both tandem and ovoids in the cervix. Depending also on the tumour stage, two orthogonal radiographic X-ray films are taken using a simulator machine. The treatment machine used in the study is AMRA-Curietron. The maximum activity of the source was 259GBq. It has five channels which is a manual remote afterloader. In clinical practice, the treatment time t is very short(only some few days) for such low dose rate brachytherapy source like Cs-137 which lasts only for some few days in comparison with the half life of the Cs-137 source. The mathematical equation for the calculation of treatment time is written as t=D/D. Hence t is the treatment time of the radioactive source of patients undergoing intracavitary brachytherapy treatment, D is prescribed dose to a reference point and D is the dose rate to the same reference point. Results: The calculated treatment time of the Cs-137 brachytherapy source for different source arrangements or channels used in clinical practice at the brachytherapy Centre have been determined. Also provided, are the prescribed doses to the reference point and the calculated dose rate to the same point. The source arrangements in the channels are (1-2-5), (1-3-5), (1-4-5) and (1-5) respectively. Conclusion: The treatment time of Cs-137 low dose rate radioactive source for intracavitary brachytherapy treatment has been determined using the Manchester System. The results show that the treatment time depends on the dose prescribed to a reference point, which is usually set up by the oncologist at the Oncology center and the dose rate to the same point, which is determined by the dosimetrists using the Treatment Planning System (TPS) at the facility. The treatment time for advanced stages of the tumors were found to be much higher than the early stages of tumours.
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Breast cancer in young women: The effect of age on tumor biology and prognosis
Poornima Sivakumar, Chandni Ravi, Gabriel Rodrigues
March-April 2015, 4(2):165-169
Background: Breast cancer (BC) is primarily a disease of older or postmenopausal women. Due to the small number of reported patients and difficulty in diagnosing BC in younger women studying this disease in this group has been challenging. Controversy exists regarding the relationship between age and prognosis as young women have generally been found to have a poor prognosis. This study compares breast carcinoma in women above and below 35 years of age highlighting age as an adverse factor in the presentation, recurrence, and prognosis of the disease. Materials and Methods: Two hundred and seventy-nine patients, having undergone a BC operation at a tertiary-care center between June 2005 and June 2010 were studied. Prognosis of breast carcinoma in women above and below 35 years was compared based on the stage and grade of the disease at the time of presentation, estrogen receptor/progesterone receptor (ER/PR) and HER2/neu status, recurrent disease on follow-up and mortality. Comparisons between these factors in the two groups were drawn using SPSS version 16.0. Results: Forty-seven patients were under 35 years (16.8%), and 232 patients were older than 35 years (83.2%). Women under 35 presented more often with stage 3 or 4 as compared to the other group. Mammogram grades were similar in both age groups. 52.5% of women below 35 years were given neoadjuvant chemotherapy versus 31.5% of women above 35 years. 93% of women in both age groups underwent surgery. There was statistically significant increased ER/PR negativity, HER2/neu positivity among women under 35 years of age as compared to the older group. 12.76% of women below 35 years had locoregional recurrence versus 5.17% of women above 35 years. 17.02% of women below 35 years had metastasis at the time of follow-up versus 6.46% of women above 35 years. Mortality in women under 35 years was 23.4% compared to 16.37% in women above 35 years. Conclusions: Young age (<35 years) is strongly associated with several poor prognostic factors. There is a need for aggressive management of BC in these women to reduce the incidence of recurrence, metastasis, and mortality.
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Polymorphic variants of mismatch repair gene human MutS homologue-2 influence oral squamous cell carcinoma in a South Indian population
Kanaram Choudhary, Sanish Sathyan, VT Beena, Swagatika Panda, R Sivakumar, Anil Ahuja, Moinak Banerjee
March-April 2015, 4(2):170-174
Background: Oral cancer is the third most common cancer in India. It is a multifactorial disease. Cells with defective mismatch repair (MMR) mechanisms cannot correct genetic errors that occur during cellular replication, resulting in a reduction in the fidelity of DNA repair. The objective of this study is to investigate the role of polymorphic variants in MMR gene human MutS homolog-2 (hMSH2) in oral squamous cell carcinoma (OSCC) and associated clinicopathological features in Malayalam speaking population from Kerala. Materials and Methods: Patients diagnosed with OSCC, without superimposed premalignant and other malignant conditions were selected for polymorphism screening of hMSH2 gene. Two single nucleotide polymorphisms (SNPs), rs2303428 (hMSH2-6C/T) located at −6 of the 3' splice acceptor site of exon 13 and rs61756463 (hMSH2 471C/A) located in exon 3 of hMSH2 were selected based on their functional relevance. Results: Polymorphism screening of hMSH2 gene suggests that rs2303428 was associated with both allelic and genotypic combinations with OSCC. In allelic level, the T allele was associated (P = 0.009) with OR of 2.86, whereas in genotypic level the TT genotype was found to be significantly associated (P = 0.012). In silico prediction of functional implication of this SNP indicated altered transcriptional regulation with functional significance score of 0.176. Although assessing the intergroup comparison within OSCC patients for age (≤50 and >50), gender and histo-differentiation grading, we could not find any association with any of these variables. Conclusion: Certain polymorphic variants in the MMR gene hMSH2 can result in OSCC in Malayalam speaking south Indian population and could indicate defective repair mechanism or Microsatellite instability. Distribution of rs2303428 allele had clear ethnic distribution across world population.
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Feasibility of organ preservation in muscle-invasive transitional cell carcinoma bladder: A single institutional approach
Chhaya Roy, Krishnangshu B Choudhury, Anshuman Ghosh, Animesh Saha, Ritam Joarder, Suresh P Akhil
March-April 2015, 4(2):175-182
Background: Trimodality treatment initial transurethral resection of the bladder tumor [TURBT] followed by concurrent chemotherapy and radiation and organ preservation have been gradually replacing the radical cystectomy in muscle-invasive transitional cell carcinoma (TCC) of bladder. Aims: The aims of this study is to determine the clinical effectiveness, safety and protocol completion rate of trimodality treatment in muscle-invasive TCC of the bladder. Settings and Design: Prospective randomized and open-labeled study. Subjects and Methods: Patients with TCC of bladder, American Joint Committee on Cancer tumor node metastasis (TNM) Bladder Cancer Staging (2002) T2-3, N0, M0. Were underwent TURBT followed by three cycles of neoadjuvant chemotherapy with methotrexate, vinblastine, adriamycin, and cisplatin regimen. The patients were then randomized to receive either concurrent cisplatin 75 mg/m 2 in week 1 and 4 (arm-A) or no cisplatin (arm-B) along with external beam radiation therapy (EBRT) 45 Gy, in 25 fractions over 5 weeks. 4 weeks after completion of the initial phase of treatment, all patients were re-evaluated with TURBT. Those with complete remission (CR) received additional 15 Gy of EBRT in 8 fractions, while patients with residual disease were recommended for immediate radical cystectomy. All the patients of arm-B received boost dose of 15 Gy of EBRT. Statistical Analysis Used: The major statistical endpoints of this study were the CR rate at 8 weeks post-concurrent chemoradiotherapy (CCRT) and only radiotherapy. Statistical significance was accepted at the P < 0.05 (two-sided) level. Statistical analysis was performed entirely using the Statistical Package for the Social Sciences for Windows, version 17 (SPSS Inc., Chicago, IL, U.S.A.). Results: 8 weeks after completion of treatment 13/16 (81%) patients were in CR in CCRT arm (arm-A) compare to 6/15 (40%) patients receiving radiation only (arm-B). Conclusions: Patients, after TURBT receiving CCRT, had a better chance of organ preservation (81%) than those receiving radiation only.
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Fibroadenoma: A harbor for various histopathological changes
K Geethamala, BR Vani, V Srinivasa Murthy, M Radha
March-April 2015, 4(2):183-187
Background: Fibroadenomas (FAs) are the most common benign tumor of the female breast constituting approximately one-third of all benign breast lesions. Epithelial elements of FA can exhibit spectrum of proliferative changes similar to those found in normal breast counterparts. Objective: To study and analyze various histopathological changes within FAs. Materials and Methods: A 3 years retrospective study conducted in the Department of Pathology Employee's State Insurance Corporation (ESIC) Medical College and Postgraduate Institute of Medical Sciences and Research and ESIC Model Hospital, Rajajinagar. Bengaluru. 372 diagnosed cases of FAs were retrieved and examined for various changes associated within it. Relevant clinical data were analyzed. Results: FAs were commonly encountered in the age group of 21-30 years (63.2). 42.5% of FAs had associated pathological entities. Complex FAs were 1.5%, 0.9% of infarcts and 0.3% of FA with extensive squamous metaplasia. 24.3% of FA with fibrocystic disease, 12.3% of FA with varied degrees of hyperplasia and 0.3% of invasive carcinoma was noted. Incidental detection of even single case of carcinoma within FA emphasizes the need for comprehensive histopathological examination of all FAs. Conclusions: The present study highlights various gamut of nonproliferative and proliferative lesions seen in amalgamate within FAs. Early detection enables further management and surveillance of the concerned patients.
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Serum/plasma DNA methylation pattern and early detection of breast cancer
Arootin Gharibiyan, Seyed Ahmad Hashemi, Mahdie Hadi, Hamed Abdolghafoorian, Ali M Ardekani
March-April 2015, 4(2):120-128
Breast cancer is the most common cancer among women. With its fatality rate reduced significantly if diagnosed early, developing cost-effective, noninvasive methods of early detection is highly investigated. Currently, mammography with magnetic resonance imaging is considered the optimal method of early detection in women who are at a significantly raised risk of developing breast cancer. Due to environmental effects and life-style changes in recent years, elevation of the risk of cancer incidents in lower risk populations is observed and therefore, the development of a relatively easy-performed and low-cost method for early detection of cancer in general and breast cancer in particular is needed. Serum-based analysis techniques have been quite popular subject of research recently as they can be performed with low technical knowledge, become automated and are cheap. In the present article, we have reviewed the literature related to the use of DNA methylation-detection based techniques for diagnosis of early-stage breast cancer using serum or plasma circulating tumor DNA and their power as a future biomarker. A reference to all genes that is reported to be differentially methylated in breast cancer accompanies the article.
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Tracheal tumor: A diagnostic and therapeutic dilemma
Rajesh Kumar, Akhil Kapoor, Ramesh Purohit, Murali Paramanandhan, Tanya Syiem, Harvindra Singh Kumar
March-April 2015, 4(2):129-133
Tracheal tumors are quite rare, contributing only 0.1-0.4% of all tumors. We report a case of 42-year-old male who presented with right sided neck swelling along with pain and cough for last 1-month. He was diagnosed to be a case of tracheal squamous cell carcinoma. Surgical debulking followed by concurrent chemoradiation was planned. After 6 months follow-up, there was no residual disease and the patient is symptom-free. Along with the case, a brief review of the literature is also presented.
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