Early-Onset Gastric Cancer from a Geographic Area of High Gastric Cancer Incidence in North-East India: a Retrospective Study.

We aim to report about the clinico-pathological characteristics of early-age gastric cancer in North-East India. It is a retrospective and observational study conducted in a tertiary care cancer centre in North-East India. We reviewed physical case records and the hospital electronic medical record system. The study population included all patients of age 40 years or less, with a confirmed diagnosis of gastric adenocarcinoma, who received treatment in the institute. The duration of the study was from 2016 to 2020. Data was collected using a pre-designed proforma, and the results were presented as percentages, ratios, median values and range. A total of 79 patients with early-age gastric cancer were found during the study period. There was female preponderance (45:34). Out of the total, 43% presented in stage IV. Most of them had good performance status (87.3% had ECOG 0-2), and none of them had documented co-morbid illness. Poorly differentiated adenocarcinoma and signet ring cell carcinoma were seen in 36.7% and 25.3% patients, respectively. Only 25 patients (31.6%) underwent definitive surgery, and they had a high nodal burden with a median metastatic lymph nodal ratio of 0.35 (range 0 to 0.91). Out of them, 40% developed systemic recurrence within a short span of time (median time to recurrence being 9.5 months). Peritoneal recurrence was the most common site of failure (80%). Early-age gastric cancer has been associated with aggressive pathological features and poor clinical outcomes in North-East India.

Pelvic Exenteration for Locally Advanced Rectal Cancer: an Initial Experience from North-east India.

Pelvic exenteration is a surgery done to achieve margin negative resection in locally advanced rectal cancer infiltrating pelvic organs anterior to it. A retrospective observational study of patients undergoing pelvic exenteration for locally advanced rectal cancer was done at a single surgical unit of a tertiary care cancer centre. The period of study was from 1st January 2019 to 30th June 2021. A total of twelve patients underwent pelvic exenteration for locally advanced rectal cancer during the study period. The median duration of surgery was 310 min (range 250 to 380 min). The median duration of hospital stay was 14 days (range 12 to 30 days). Seven patients had documented postoperative complications, either major or minor, with a complication rate of 58.3%. Three patients required re-admission for complications. Two patients had COVID19 infection in the postoperative period but had uneventful recovery. Margin negative resection (R0) was achieved in eight patients (66.67%). Pelvic exenteration for locally advanced rectal cancer is a definitive surgery associated with a high morbidity rate. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01529-3.

Reconstruction and Outcome of Foot Defects Following Oncological Resection-Experience from a Cancer Centre in North-East India.

Solid tumours around the foot are rare and include soft tissue sarcomas, skin and bone malignancies. Extended soft tissue defects due to oncological resection result in the loss of shock-absorbing and friction resistant tissue, which leads to altered walking patterns and pain. Replacement of plantar tissue requires soft tissue resistant to weight, pressure and shear stress. The other important desired goal of foot reconstruction is short wound healing time in order to allow adjuvant therapy at stipulated time. This is a retrospective study from March 2016 to October 2019. A total of twenty-one (n = 21) patients were operated for foot malignancies during this period in our institute and the resulting defects were reconstructed using various methods. Different reconstructive surgeries were performed depending on tumour size, location and general health status of patients. The length of hospitalization and the presence of local postoperative complications were assessed. Functional outcomes were measured in terms of MSTS score. Average age of the series is 53.1 years. Sixty-six percent of the patients (n = 14) presented with tumour at the weight bearing areas and 33% patients (n = 7) at the non-weight bearing areas of the foot. Fifty-seven percent of patients (n = 12) presented with malignant melanoma of foot, squamous cell carcinoma was seen in 33% (n = 7) patients and 4% patients (n = 1 each) presented as osteosarcoma and malignant peripheral nerve sheath tumour respectively. The mean MSTS score in patients with weight bearing areas (location) is statistically significant (p = 0.031). There is a significant correlation between the surgical complications and follow up MSTS score (p = 0.046) which signifies that flap related complications result in lower MSTS score. The mean MSTS score was 22.71/30. Complications were observed in three cases which included partial flap necrosis, graft loss and foot stiffness. Simple skin grafts to local flaps maybe a viable option in a limited resource setting based on the location of defect. Free tissue transfer is the ideal choice in case of weight bearing areas to achieve acceptable outcomes.

Morbidity Following Groin Dissection in Malignancy Remains a Challenge: an Experience from North-East India.

Inguinal lymph nodal dissection is notoriously associated with high morbidity. Various risk factors and technical modifications have been described in the past to overcome complications like lymphedema, wound breakdown, and infection which adversely affect the postoperative outcome and quality of life of the patient. This is a retrospective observational study from 1 January 2016 to 31 December 2019 of patients who underwent inguinal/ilio-inguinal block dissection for malignancy. Lymphedema was the most frequent morbidity seen (24%). The mean hospital stay of patients following surgery was 9.7 days (range 4 to 28 days). The inguinal drain was removed on a mean of 17.7 days (range 4 to 21 days), while mean iliac drain removal time was 11.7 days (range 4 to 21 days).

Sentinel Lymph Node Biopsy Using a Single-Dye Technique in a Cancer Center of North-East India: Cancer Epidemiology, Screening and diagnosis.

Background Sentinel lymph node (SLN) is the first node to receive the drainage directly from a tumor. SLN biopsy can be done in lieu of a formal lymphadenectomy in selected clinically node-negative cancers and minimizes morbidity compared with the latter. Methods This prospective study was done in patients with operable clinically node-negative breast cancer, penile cancer, and malignant melanoma of extremities in a cancer center of North-east India from January 2019 to December 2019. All the patients underwent formal lymph nodal dissection after the SLN biopsy. Besides intraoperative frozen section study of the sentinel node(s), all the specimens, including the sentinel node(s), were subjected to paraffin section histopathology. Results SLN was identified successfully in 96% of patients. Mean number of sentinel node(s) dissected was 2.3. Study of SLN biopsy with methylene blue dye for staging was done with 100% sensitivity and 95.3% specificity. The SLN procedure was able to negatively predict the drainage nodal basin in 100% with an overall accuracy of staging of 96.5%. The true-positive rate noted was 88.8%, and the false-positive rate was 4.6%. Conclusions SLN using a single-dye technique reliably identifies a sentinel node. This procedure can be safely adopted in patients with node-negative cancers as mentioned above to pathologically study the drainage basin.

Postoperative pancreatic fistulas after pancreaticoduodenectomy for malignancy: A Northeast Indian tertiary cancer center study.

BACKGROUND AND AIM: Postoperative pancreatic fistula (POPF) is an important cause of major morbidity and mortality after pancreaticoduodenectomy. We intend to estimate the incidence and study the risk factors and outcomes of patients who developed this dreaded complication. METHODS: This is a retrospective observational study. We included all patients who underwent pancreaticoduodenectomy at a specialized surgical unit of a single tertiary care cancer center in Northeast India. The period of study was from 23 April 2012 to 27 December 2019. The 2016 update on the definition of POPF by the International Study Group for Pancreatic Fistula was used to define the complication. Chi-square test and Fischer's exact test were applied to categorical variables. t-test was used to quantify mean difference among continuous variables. P value <0.05 was considered statistically significant at 95% confidence interval. RESULTS: A total of 59 patients underwent pancreaticoduodenectomy during the study period with almost equal distribution among males and females (29 and 30 patients respectively). The mean age of the patients was 54.0 years (range 20-72). Grade A, B, and C pancreatic fistulas were seen in five (8.5%), three (5.1%), and two (3.4%) patients, respectively. Preoperative hyperbilirubinemia, pancreatic duct size ≤3 mm, hypoalbuminemia, preoperative biliary decompression, and prolonged duration of surgery were identified as risk factors for POPF. POPF also resulted in increased 90-day mortality (20%). CONCLUSION: POPF remains a potentially life-threatening complication of pancreaticoduodenectomies. The knowledge and management of modifiable risk factors for this condition may help in mitigating this problem.

Impact of COVID-19 Pandemic on a Tertiary Care Center's Surgical Volume and Outcomes: a Single Institutional Study from Northeast India.

In this study, we aimed to compare the surgical volume and outcomes between this COVID-19 period and data from non-COVID-19 period of last year. A retrospective observational study was done in one single surgical unit of a dedicated oncology center in a peripheral location in India. The comparison was done between patients undergoing major cancer surgery during the COVID-19 pandemic period of 1st April to 30th June 2020, when a nation-wide lockdown was in force, to a comparable period of last year. Statistical analysis was done using SPSS software 20.0. A total of 72 patients underwent major cancer surgery during this period, with surgery for breast cancer (n = 26) being the major sub-site operated. This was a significant decrease from the total 209 major cancer surgeries performed during a similar period of last year (2019) (p < 0.05). There were several reasons for the decrease in surgical numbers, including the difficulty in travel and accommodation during the lockdown period. The mean distance of patient's residence from the treating hospital was 45.7 km (range 4 to 165 km). Public transport was in a limbo and inter-state travel was restrictive with mandatory quarantine rules in effect. Morbidity associated with major surgeries was observed to be significantly less during the COVID-19 period compared to the pre-COVID-19 times (8.3% vs 17.2% with a p value of < 0.05), which can probably be attributed to the lesser number of complex surgical procedures being performed. There was no significant difference between the total mortality percentages (2.8% vs 3.8%). A total of 156 PPE kits were used (3-4/per patient) throughout the in-hospital care of the surgical patients included in this study. In the midst of a pandemic, the delivery of surgical cancer care is an essential service and although the surgical volume is significantly hampered due to various reasons, the outcomes are largely unaffected.

Feasibility and Outcomes of Multivisceral Resection in Locally Advanced Colorectal Cancer: Experience of a Tertiary Cancer Center in North-East India

Purpose: Locally advanced colorectal cancer may require an en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications of multivisceral resection against the potential survival benefit. The purpose of this study is to review a single-center experience of feasibility of en bloc multivisceral resections for locally advanced colorectal carcinoma and to examine the effect of surgical experience on immediate outcome and rate of R0 resections. Methods: This is a study of 27 patients who underwent multivisceral resection for locally advanced colorectal carcinoma which was performed at our institute from January 2016 to December 2019. Among the 27 patients aged between 21 and 76 years (mean age, 48.67±7.3 years), 13 were males and 14 were females. Overall 18 patients had primary colon carcinoma and 9 had primary rectal carcinoma. All rectal cancer patients received neoadjuvant chemoradiation. All patients underwent surgery with curative intent. All patients underwent open surgery of which 66.7% underwent colectomy, 14.8% underwent anterior resection, 11.1% underwent Miles procedure, and 7.4% underwent pelvic exenteration. Results: The mean operative time was 268.14±72.2 minutes and the median amount of blood units transfused was 2.07 units. The mean hospital stay was 13.67±3.4 days. Histologically, 44.4% of patients had well-differentiated adenocarcinoma and 55.6% had moderately differentiated adenocarcinoma. The final histopathological examinatio n revealed malignant infiltration of the adjacent organs in 19/27 patients (70.4%). Pathological complete response was seen in 2 patients. R0 resection rate achieved was 96.3%. Lymph node metastasis was seen in 66.7% of patients with colon cancer and 11.1% with rectal cancer with overall mean number of harvested lymph nodes being 12.44±3.01. Postoperative complications were identified in 7 patients (25.9%), while mortality was seen in 2 (7.4%). Conclusion: Multivisceral resection for advanced colorectal cancer invading into the adjacent organ may be performed with acceptable morbidity and mortality.

A study of Human Epidermal Growth factor receptor-2 [HER-2] in Carcinoma Oesophagus [Single Institutional Tertiary cancer centre study from North-East part of India].

BACKGROUND: Oesophageal cancer both squamous cell [SCC] and adenocarcinoma have poor outcomes with high morbidity and mortality. Our hospital-based registry for year 2017-2018 showed that oesophageal cancer constituted 22.7% of annual case load. The main objective of this study was to determine the presence of HER-2 receptors in patients with oesophageal carcinoma in our region. METHODOLOGY: From September 2018 to September 2019, data regarding expression of HER-2 receptors was analysed in 133 patients of oesophageal carcinoma. Data were statistically described as frequencies (number of cases) and percentages where appropriate. Chi-square and Fischer's exact test was used to find out the association between categorical variables. A P value less than 0.05 was considered as statistical significant at 95% confidence interval. The statistical analysis was performed using SSPS [statistical package for the social sciences] software version 17.0. RESULTS: A total of 133 patients were taken into study. Majority of patients were males (96) with mean age of 52 years. Squamous cell carcinoma was predominant histology. HER-2 receptor positivity was seen in 6.01% of patients. Patients with HER-2 receptor positivity presented in advanced stage with poor functional status and poor grades of differentiation. Statistically significant correlation of Her-2 expression was seen with stage (p = 0.001) and pathology of tumour (p = 0.0001). CONCLUSION: Squamous cell carcinoma of oesophagus still predominates in North-eastern part of India. For studying the role of effective targeted therapies knowledge of frequency of HER-2 receptor positivity is of utmost importance in our population, and our study aims to answer this question. The present study shows low prevalence of HER-2 neu overexpression in our community, probably due to disproportionately high incidence of SCC compared to adenocarcinoma. Patients with HER-2 receptor positivity presented in advanced stage with poor functional status and poor grades of differentiation.

A study of outcomes, technical safety, and feasibility of D-2 lymphadenectomy in gastric cancer.

BACKGROUND AND AIM: Lymph node dissection in gastric cancer had been controversial, but recent data have led us to the conclusion that D-2 dissection should be the standard of care for potentially curable advanced gastric carcinoma. In this study, we present our single-institution experience of D-2 lymph node dissection. METHODS: From January 2013 to September 2018, 115 patients of gastric cancer were treated with D-2 gastrectomy, 91 of whom met the criteria for study analysis. Data were statistically described as frequencies and percentages where appropriate. Survival curves were plotted using the Kaplan-Meier method, and Cox regression was used to assess the risk among groups. A P value <0.05 was considered to be statistically significant at 95% confidence interval. RESULTS: The majority of patients (86.8%) had Clavien-Dindo grade I postoperative surgical complications; 90-day mortality was seen in five (5.5%) patients. Patients with stages I, II, and III had survival rates of 100%, 71.4%; 53.2%, 44.4%; and 27.8%, 28.1%, respectively, for ages <55 and >55 years. Overall recurrence free survival rates were 26 and 28% for <55 years and >55 years, respectively, with a P value of 0.570. On multivariate analysis, positive distal margin and multivisceral resection had a statistically significant hazard ratio. CONCLUSIONS: This retrospective study conducted in our institute on patients with gastric cancer undergoing D-2 lymphadenectomy has shown that the addition of D-2 lymph node dissection, when performed at high-volume centers, have acceptable morbidity and mortality rates. This can be seen from our grades of postoperative surgical complications, 90-day mortality, and overall 5-year survival.

Nasojejunal Feeding Is Safe and Effective Alternative to Feeding Jejunostomy for Postoperative Enteral Nutrition in Gastric Cancer Patients.

Background and Aim Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them. Materials and Methods It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively. Results A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor. Conclusion Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.

Radical Gastrectomy: Still the Gold Standard Treatment for Gastric Cancer-Our Experience from a Tertiary Care Center from Northeast India.

Gastric cancer (GC) is common in the northeast and southern parts of India. Radical surgery is the cornerstone of treatment and offers the only chance for cure. This study was conducted to assess the outcomes of all resectable gastric cancers that presented to our tertiary cancer center in Northeast India. All patients undergoing upfront surgery for gastric cancer with curative intention between 2012 and 2017 were included in the study. A total of 116 patients who underwent upfront radical gastrectomy were included in the study. Males (58.6%) were more common than females (41.4%). Mean age at presentation was 56.12 years (range 26-89). The most common mode of presentation was pain abdomen (53.8%). The most common location of tumor was the distal part (81%) followed by the proximal part (10.3%). The most commonly done procedure was distal radical gastrectomy (56.9%) followed by subtotal gastrectomy (32.8%). Median number of lymph nodes isolated was 14. Fifty-four patients received adjuvant chemotherapy while 32 patients received adjuvant chemoradiation (CTRT). At a median follow-up of 14 months (range, 2-78 months), overall 5-year survival was 23.75% (mean survival 33.77 months, median survival 24 months). The 5-year survival for stages I-III was 100%, 26.25%, and 11.25%, respectively (P < 0.001). Though perioperative chemotherapy has a role in gastric cancer, it is not the substitute for radical D2 gastrectomy which is still the gold standard treatment especially in high-volume centers.

A Study of Hormonal Receptors in Esophageal Carcinoma: Northeast Indian Tertiary Cancer Center Study.

Background Esophageal cancers, both squamous cell and adenocarcinoma, have poor outcomes with high morbidity and mortality. Our hospital-based registry for the year 2017 to 2018 showed that esophageal cancer constituted 22.7% of annual caseload. Most of our patients present in advanced stages. The aim of this article was to study the role of hormonal receptors in patients with esophageal cancer. Methods This is a single-institution, prospective, observational study in patients with esophageal carcinoma. Hormonal receptors (estrogen receptor [ER]-α and progesterone receptors) were studied in tumor tissue. Of 160 patients, receptor status was analyzed in 133 patients. Chi-square test was used for the correlation of categorical variables. The value of p < 0.05 was considered as statistically significant. Results A total of 133 patients was taken into the study of which 96 were males and 37 were females. The mean age of patients was 52 years. Carcinoma esophagus was predominantly seen in males. Estrogen and progesterone receptors were positive in 9.02 and 4.51% of the study population, respectively. Patients with hormonal receptor positivity presented with poor functional status, higher grades of dysphagia, higher stage, and most of the tumors were poorly differentiated with statistically significant p -values. Conclusion Despite recent advances in various fields of oncology, outcomes of esophageal carcinoma have not improved significantly. Hence, a study of new pathways of pathogenesis in carcinogenesis of esophageal carcinoma is essential. Few recent evidences including our study shows that the hormonal milieu is responsible in the pathogenesis of carcinoma esophagus. The utilization of this data and future study of the role of hormonal therapy might lead to improved outcomes in patients with carcinoma esophagus.

A Study of Clinical Presentation and Management of Malignant Gastric Outlet Obstruction (Northeast India-Based Single-Centre Experience).

Gastric outlet obstruction (GOO) occurs when there is mechanical obstruction impending gastric emptying. GOO has both benign and malignant aetiologies. In this paper we want to discuss, clinical presentation and management of malignant GOO. This is a retrospective observational study of 5 years in patients presenting with malignant GOO. Study was conducted in Dr. B. Borooah Cancer Institute, Guwahati, India. Patients with malignant GOO who were operated were included in this study. Chi-square test was used to evaluate association between categorical values. Independent t test and one-way ANOVA (analysis of variance) was used for continuous variables. A p value < 0.05 was considered statistically significant at 95% confidence interval. Data were analysed using SPSS (Statistical Package for the Social Sciences) software. A total of 107 patients were included in the study. Mean age of patients was 51 years. Carcinoma stomach was the most common cause of GOO, followed by carcinoma gall bladder, pancreatic cancer and duodenal cancer in decreasing order of frequency. Gastrojejunostomy was done in 96 patients, and palliative gastrectomy with gastrojejunostomy was done in 11 patients. There was improvement in gastric outlet obstruction score in most of the patients after GJ with acceptable patency rates at the end of 90 days. Low albumin levels and poor preoperative performance status were associated with increased 90-day mortality. Patients with malignant GOO usually present in poor general condition. Carcinoma stomach was the major cause of GOO in our setup. Adequate preoperative resuscitation, nutritional assessment and correction of malnourishment are of utmost importance for improving outcome of patients. Surgical gastroenterostomy was effective for palliation of obstructive symptoms in our study with improvement in post-operative oral intake and improved quality of life. Our study of 107 patients with GOO has shown that surgical palliation of GOO in the form of gastrojejunostomy improves oral intake of patients with improved post-operative gastric-outlet obstruction scores. Low albumin levels and poor preoperative poor performance status were associated with increased mortality at the end of 90 days.

Reverse sural flap - A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India.

BACKGROUND: Soft-tissue management around the lower third of the leg and foot presents a challenge to the surgeon. To achieve local control of tumor, additional surgical margins are required, thus creating large soft-tissue defects. The reverse sural artery flap (RSAF) is a popular option for many of these defects. MATERIALS AND METHODS: This is a retrospective study of 26 patients who underwent resection of tumor around the lower leg, ankle, and foot, and reconstruction with RSAF was performed at our institute from 2012 to 2018. RESULTS: Among the 26 studied patients, aged between 22 and 71 (mean age: 50.8) years, 5 were female and rest were male. The most common site of involvement by tumor was heel (42.3%), followed by sole (26.9%). The most common histopathological diagnosis was melanoma (61.5%), followed by squamous cell carcinoma (26.9%) and soft-tissue sarcoma (11.5%). CONCLUSION: The distally based sural flap is a reliable flap for the coverage of soft-tissue defects following oncological defects of the distal lower extremity and foot.

Delays in Diagnosis and Treatment of Breast Cancer and the Pathways of Care: A Mixed Methods Study from a Tertiary Cancer Centre in North East India.

INTRODUCTION: In India, mortality rate in breast cancer is high because more than half are diagnosed late at locally advanced or metastatic stages. This might be due to presentation delay (recognition of symptoms to first provider consultation) and treatment delay (first provider consultation to initiation of treatment), together known as overall delay. We aimed to estimate the overall delay in diagnosis and treatment in breast cancer and the associated factors, describe pathway of care and explore the reasons for delay from a patients' and providers' perspective. METHODS: Explanatory sequential mixed-methods study with a quantitative component (retrospective cohort study including breast cancer patients registered at Dr. Borooah Cancer Institute (BBCI), Guwahati during February-June 2019) followed by descriptive qualitative component (in-depth interviews with 15 patients and 10 care providers). RESULTS: Of 269 breast cancer patients, median (Inter Quartile Range) overall delay was 203 (110-401) days, presentation delay was 35 (10-112) days and treatment delay was 130 (75-258) days. Majority of patients approached private sector (190, 70.6%) as the first care provider. Nearly half of all patients (136, 50.6%) visited one health care provider before reaching the BBCI and another one-third (90, 33.5%) visited two providers. Reasons for presentation delay were misconception about the disease, perceived stigma, fear and denial of cancer, attribution of symptoms to trivial conditions, family responsibilities and embarrassment of breast examination by a male doctor. Treatment delay was due to initial visit to, misclassification of disease severity, dissatisfaction with care at public facilities, poor accessibility and affordability, fear of treatment and its side effects. CONCLUSION: Treatment delay was the major contributor to overall delay. Private providers need to be sensitized and trained in screening of breast cancer and referral of suspected cases of cancer. More awareness is needed about warning symptoms of breast cancer and misconceptions regarding the disease.
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Primary Ovarian Carcinoma with Rectal Metastasis-a Rare Presentation (a Case Report).

Rectal metastasis from primary ovarian cancer is a rare condition. In this case report, we present a case of 45-year-old female presented with chief complaint of pain abdomen and vomiting and with on and off history of per rectal bleeding. On examination, patient was pallor, hemoglobin level of 5.5 for which she was admitted. On per rectal examination, there was circumferential rectal growth around 7 cm from anal verge. Imaging was suggestive of ovarian lesion with rectal growth. Biopsy and immunohistochemistry of rectal growth was suggestive of metastatic well-differentiated papillary adenocarcinoma probably of ovarian origin. In view of its rare presentation, we want to report this case.