Metastatic involvement of the spleen by endometrial adenocarcioma; a rare asylum for a common malignancy: a case report.

BACKGROUND: Metastatic involvement of the spleen by solid tumors is a rare clinical entity; those coming from endometrial adenocarcinomas are exceptionally rare. Spleen is an uncommon site for metastatic deposits due to its specific anatomy and microenvironment. Typically, splenic metastasis from endometrial carcinomas present months to years after curative surgery, chemotherapy or radiotherapy. The most common complaint in symptomatic patients is abdominal pain localized to the left hypochondrium. Most however, are asymptomatic only to be picked up on vigilant routine ultrasonography or computerized tomography during follow up. We report the case of a 54-year-old woman who presented to us after 50 months of total abdominal hysterectomy and bilateral salpingo-oophorectomy for an endometrial adenocarcinoma. She had severe abdominal pain localized to the left hypochondrium as the presenting complaint. To the best of our knowledge, this is the 1st case to be reported from Pakistan with 14 cases reported prior to our report. All past cases report the endometroid variant of endometrial adenocarcinoma as the primary tumor and our patient was a victim to the same variant. CASE PRESENTATION: A 54-year-old, nulliparous widowed woman presented with severe abdominal pain in the left hypochondrium for the last 4 months. The pain radiated to the left shoulder and was exacerbated with deep breathing. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy done 50 months back for stage 1a endometroid endometrial adenocarcinoma. Clinical examination revealed tenderness in the left hypochondrium but no visceromeglay was appreciable. Ultrasonography and computerized tomography revealed a space-occupying lesion within the spleen with associated splenomegaly. Computed tomography further suggested a large splenic abscess however the patient did not have fever, vomiting or leukocytosis which are the hallmarks of a splenic abscess. A splenectomy was performed for her complaints. On histopathology a metastatic adenocarcinoma was identified consistent with the primary tumor. The tumor was CK7, CA-125 and epithelial membrane antigen positive (EMA). The patient was then referred for further chemotherapy. CONCLUSION: From this case we conclude, that although very rare, the spleen is a potential site for metastasis in endometroid endometrial adenocarcinoma. Since most patients are asymptomatic, routine examinations and imaging can identify its presence and avoid complications. If the practice is employed with vigilance, we may expect the clinical event to be diagnosed more frequently. The standard treatment is a classic splenectomy followed by chemotherapy.

Knowledge, attitude and practice of a Pakistani female cohort towards breast cancer.

OBJECTIVE: To note knowledge, attitude and practices of females towards breast cancer. METHODS: This KAP study was carried out at Holy Family Hospital, Rawalpindi from January to May, 2009. One thousand randomly selected adult females presenting as patients (excluding those with breast complaints) and their accompanying attendants were inducted and interviewed. Pre tested, structured questionnaire, containing 34 (open and closed ended) questions, along with demographic profile was used to gather data which was analyzed using SPSS version 13. Chi square test was applied at 5% level as test of significance. RESULTS: Mean age of participants was 32.39 +/-10.47 years. Majority were married (88%), housewives (88%), and urban dwellers (75%) with average household income of Rupees 3000-6000 (33%). Majority (82.9%, n=829) had heard of breast cancer. Further questions were asked from these females. More than 50% participants were aware of cancer's relationship with increasing age, lack of breast feeding, painless lump, obesity, and smoking. Except for breast lump, over 50% participants had knowledge about breast cancer symptoms. >50% subjects had knowledge about diagnostic modalities, treatment and its relation with outcome. Majority (>90%) had positive attitude and intended to see a doctor immediately if they ever felt a breast lump, but had poor (28.3%) practices regarding breast self examination. CONCLUSION: Majority of study participants had limited knowledge, poor practices, but positive attitude towards breast cancer.

Evaluation of the aetiological spectrum of obstructive jaundice.

BACKGROUND: Jaundice is a common problem in medical and surgical gastroenterological practice. The surgical jaundice can be caused by the obstruction of the bile duct as with gall stones, strictures, malignancy, such as cholangiocarcinoma (in which the jaundice is persistent and progressive), periampullary carcinoma, carcinoma gall bladder and carcinoma head of pancreas. The objective of this descriptive study was to evaluate the Etiological spectrum of obstructive jaundice. METHODS: A prospective, descriptive study was carried out at Surgical Unit-II Holy family Hospital, Rawalpindi, from mid of May 2006 till March 2007. Sixty patients, who presented in the surgical OPD of Holy family Hospital, were included in the study. Thorough history and physical examination was followed by biochemical tests and various investigations like USG abdomen, ERCP, CT-Scan, & MRCP and histopathology. The data was analyzed using SPSS ver 14.0. RESULTS: Of the 60 patients; 40 (66.66%) were male and 20 (33.33%) were female, their mean age being 49.50 years. Malignant obstructive jaundice was seen in 34 (56.66%) patients while 26 (43.33%) had benign etiology. Amongst the commonest symptom; clay coloured stools (75%) was more frequent in patients with malignant disease whereas abdominal pain (51.66%) was most common in benign conditions. Commonest malignancy was Carcinoma (Ca) of the head of pancreas 18/60 (30%) followed by Ca gall bladder 8/60 (13.33%), cholangiocarcinoma 7/60 (11.66%), and periampullary carcinoma 1/60 (1.66%). Choledocholithiasis 21/60 (35%) was the commonest benign cause followed by stricture of common bile duct 3/60 (5%) and acute pancreatitis 2/60 (3.33%). CONCLUSION: Obstructive jaundice is common amongst females and the cause is mostly malignant. Ca head of pancreas is the commonest malignancy while Choledocholithiasis is the commonest benign cause. USG, ERCP and CT-Scan are important diagnostic modalities for evaluation of patient with obstructive jaundice with ERCP having the additional advantage of being therapeutic as well.