Primary adrenal teratoma: An unusual tumor - Challenges in diagnosis and surgical management.

We report a rare case of a 25-year-old lady who presented with right hypochondriac pain associated with weakness for 3 months. Her hormonal evaluation was normal. Computed tomography scan revealed an adrenal mass for which a right open transperitoneal adrenalectomy was performed, and the lesion was diagnosed as mature teratoma on histopathological examination. Teratoma is an unusual neoplasm which arises from one or all the three germ layers. Extragonadal teratomas are rare in adults as compared to children and are mostly retroperitoneal in location, constituting only 4% of all primary teratomas. Primary adrenal teratomas are even rarer and to the best of our knowledge, only eight cases have been reported in adults in the past 10 years. Adrenal teratoma can pose a diagnostic challenge because radiologically it mimics myelolipoma, angiomyolipoma, liposarcoma, or pheochromocytoma. Mature teratomas are usually benign but may possess malignant potential, the chances of which are greater in adults as compared to children, making it an important entity requiring a proper diagnosis and management.

Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose?

AIMS/HYPOTHESIS: We studied the bacterial aetiology and antibiotic sensitivity pattern of diabetic foot ulcers in India. METHODS: Records of 447 hospitalised patients between 1991 and 2008 were retrospectively analysed between two time periods (before and after 1999) to compare bacterial aetiology and antimicrobial sensitivity patterns. The first three consecutive cultures from the same wound during treatment were evaluated. RESULTS: Of 1,632 cultures, 66% were polymicrobial, 23% monomicrobial and 11% sterile. In the monomicrobial group, 14% (n = 228) of cultures were Gram-negative, whereas 9% (n = 147) were Gram-positive. The most common pathogens in the first culture were Pseudomonas aeruginosa (20.1%), Staphylococcus aureus (17.2%) and Escherichia coli (16.3%). Results for the third cultures showed persistence of P. aeruginosa (15.3%) and E. coli (14.2%). Gram-negative isolates dominated over Gram-positive ones (25.3% vs 15.1%, p < 0.05). Antibiotic sensitivity patterns before and after 1999 were: piperacillin-tazobactam 74% vs 66% (p < 0.005), imipenem 77% vs 85% (NS), cefoperazone-sulbactam 47% vs 44% (p < 0.005), amikacin 62% vs 78% (NS), ceftriaxone 41% vs 36% (p < 0.005), amoxicillin-clavulanate 51% vs 43% (p < 0.05) and clindamycin 43% vs 36% (p < 0.005), respectively. CONCLUSIONS/INTERPRETATION: Unlike in the West, in India Gram-negative bacteria were found to have always been dominant in the wounds of patients with diabetic foot infections. Infection with polymicrobial multidrug-resistant Gram-negative bacilli is common. The policy of empirical antimicrobial therapy at tertiary care needs to be changed.

Salutary effect of parathyroidectomy on neuropsychiatric symptoms in patients with primary hyperparathyroidism: evaluation using PAS and SF-36v2 scoring systems.

BACKGROUND: Indian patients with primary hyperparathyroidism (pHPT) usually present with a triad of advanced disease of bones, stones, and psychic moans. There are hardly any reports from India on the outcome of successful parathyroidectomy on psychiatric symptoms. AIMS: To evaluate the outcome of parathyroidectomy on psychiatric symptoms in Indian patients with advanced pHPT. SETTINGS AND DESIGN: Prospective study done in a tertiary care super-specialty hospital in northern India. MATERIALS AND METHODS: Health surveys using parathyroid assessment of symptom score (PAS) and SF-36v2 were carried out, to evaluate the outcome of parathyroidectomy on the psychiatric symptoms of patients. The study included 42 patients of pHPT admitted between November 2007 and December 2009 (two years). Scoring was done preoperatively; and one week, three months, six months, and one year postoperatively. STATISTICAL ANALYSIS USED: SPSS 15 software and nonparametric tests (k Independent Sample test, Kruskal-Wallis H). RESULTS: The mean preoperative PAS score was 430.87 ± 215.61 (range 40 - 880). Statistically significant reduction in scoring was observed postoperatively at one week (293.65 ± 118.31, P < 0.001), three months (109.44 ± 85.09, P < 0.015), six months (70.00 ± 71.65, P 1 < 0.05), and one year (60.10 ± 104.48, P < 0.02). Although the surgery scores for feeling irritability, forgetfulness, difficulty in getting out of chair, headache, and itchy skin did not reduce appreciably at one week, they later showed significant reduction. All other parameters showed significant reduction. The SF-36v2 ™ survey also showed significant improvement on all scores except social functioning, while physical functioning improved only after one week. CONCLUSIONS: Indian patients with advanced pHPT, after a successful parathyroidectomy, showed significant improvement in their quality of life, as evaluated by the PAS and SF-36v2 systems.

Challenges in management of phyllodes tumors of the breast: a retrospective analysis of 150 patients.

INTRODUCTION: Phyllodes tumors (PT) of the breast seem to get pre-operatively misdiagnosed as fibroadenomas resulting in inadequate resections and high local recurrence rates. MATERIALS AND METHODS: Data of 150 patients with PT of the breast managed from January, 2003 to February, 2013 were retrospectively analyzed. Statistical analysis performed using SPSS version 17 (Pearson Chi-square test and analysis of variance test for analysis). AIM: The aim of this study is to compare clinico-pathological profile and recurrence rates in patients with benign (B), borderline malignant (BL) and malignant (M) PT. RESULTS: In a total of 150 patients with PT (n = 77 B, n = 24 BL, n = 49 M), mean age was 36.92, 44.04 and 40.46 years respectively (P 0.015) and mean tumor size being 8.15 cm, 14.7 cm and 12.9 cm respectively (P 0.000). Pre-operatively cytology suggestive of PT in 24% patients with B PT and 63% in M PT; core tissue biopsy suggestive of PT in 85.4% patients with B PT and 100% in M PT. Recurrence seen in 34.7% out of which 32.7% were post-lumpectomy performed elsewhere. Majority of B PT had lumpectomy (49.3%)/wide local excision (WLE, 31.2%) compared with M PT where 55.1% had simple mastectomy (SM) due to large tumor size. Local recurrence was more in M PT (53%) compared with B PT (20%). We found recurrence rates in L (39.3%) compared with WLE (27.3%) and SM (33.9%) (P 0.049). CONCLUSIONS: Larger tumor size, incomplete resection and M/BL histology predicted higher recurrence in PT. Core biopsy is much more accurate than fine needle cytology in the diagnosis.