Primary leiomyosarcoma kidney - A rare entity with a diagnostic challenge.

Primary leiomyosarcoma kidney is a rare tumor with an aggressive nature. Leiomyosarcoma is one of the common histologic types of the sarcomas, comprising 60% of all sarcomas. Sarcomatoid renal cell carcinoma is a close differential of renal leiomyosarcoma as both tumors have spindle-shaped cells. The former has a more pleomorphic character with nuclear grade four, which can be differentiated on the basis of immunohistochemistry. Hence, the diagnosis of primary renal leiomyosarcoma poses a diagnostic challenge. One such case of renal leiomyosarcoma in a 45-year-old male is being discussed here.

Aggressive angiomyxoma of renal pelvis in a horseshoe-shaped kidney: Rare tumor at an unusual site.

Mesenchymal neoplasm is rare in renal pelvic region. Aggressive angiomyxomas are the neoplasms seen predominantly in female genital region. These tumors are locally aggressive with rare cases presenting with metastasis. Its occurrence in renal pelvis is extremely rare with only five cases reported in the literature. The present case is the sixth case reported in a 15-year-old girl who presented to the surgery department as a case of horseshoe kidney. The mass was excised and a diagnosis of aggressive angiomyxoma was rendered.

Tumor budding in infiltrating breast carcinoma: Correlation with known clinicopathological parameters and hormone receptor status.

INTRODUCTION: Tumor budding (TB) is proposed as an essential step in the invasion and metastasis of various tumors. However, there is limited information about its role in breast cancer. This study was designed to assess the prognostic significance of TB in clinical practice. OBJECTIVES: To study and grade TB in patients with invasive breast cancer and to correlate it with known prognostic parameters. MATERIALS AND METHODS: In this prospective study, 40 cases of invasive breast cancer were studied over a period of 1.5 years. Tumor buds were defined as comprising five tumor cells or less at the invasive front of the tumor. Cases were separated into two groups according to TB density as low grade and high grade. Significance and correlation between TB with established clinicopathological parameters and hormone receptor status were studied by Chi-square test. P value <0.05 was considered significant. RESULTS: All 40 cases in this study were newly diagnosed cases, who did not receive any therapy. The majority of patients were premenopausal (55%), had small tumor size ≤5 cm (67.5%), had negative lymph nodes (67.5%), had grades 2 and 3 (75%), and presented in stages 1 and 2 pathological stage (62.5%). The majority were estrogen-receptor-negative (62.5%), progesterone-receptor-negative (65%), and human epidermal growth factor receptor-2-positive (52.5%). Higher grade TB was observed in larger tumor (P = 0.03), in higher stage (P = 0.046), and in tumor having lymphovascular emboli (P = 0.03) when compared with small size, lower stage, and tumor with no lymphovascular emboli, respectively. CONCLUSION: As higher grade TB was associated with larger, higher stage tumor, and in tumor having lymphovascular emboli, it can be recognized as an easily identifiable prognostic factor.

Utility of FNAC in Dermatological Manifestations of Metastatic Cancer with the Review of the Literature.

OBJECTIVES: Cutaneous metastasis (CM) though rare, indicates a terminal event in any malignancy and has a grave outcome. The present study reiterates the role of fine needle aspiration cytology (FNAC) in the diagnosis of metastatic cutaneous nodules. MATERIALS AND METHODS: From 2015 to 2017, the department received 22,000 cases for FNAC. Among these cases, aspirations from the skin and subcutaneous region were performed on 6,083 cases. After excluding primary tumors of skin/subcutis, 25 cases on cytology were suggestive of metastasis. Clinicoradiological and histopathological profiles in these cases were reviewed. RESULTS: Among these 25 patients, the male to female ratio was 1:1.09 (F, 12; M, 13) in the age group of 18-72 years. Most common primary malignancy in females was of breast and in males was gall bladder. The most common manifestation was a palpable skin nodule, with the abdominal wall being the predominant site. The most common diagnosis, on cytology, was metastatic adenocarcinoma. CONCLUSION: FNAC is a minimally invasive method, which aides in prompt detection and appropriate management of cases presenting with skin nodules and clinically unsuspected of malignancy. Whereas in known primary tumor, it indicates dismal prognosis by diagnosing CM; in cases with unknown primaries, cytomorphology in conjunction with clinicoradiological findings often gives a clue to the possible primary site.

Haemophilic pseudotumour: surgical management of a rare case.

Haemophilia is a common cause of genetically inherited bleeding disorders. Pseudotumours occur in 1-2 % of persons with severe forms of haemophilia. These are a result of repeated haemorrhage into soft tissues, subperiosteum or a site of bone fracture with inadequate resorption of the extravasated blood. There are a number of therapeutic alternatives for this dangerous condition: surgical removal, percutaneous management, irradiation, embolization etc. In this case report, we describe the natural history, clinical course and successful surgical management of a patient with haemophilia who presented with a massive pseudotumour. We also briefly review the relevant literature on the various therapeutic modalities that have been implemented in the management of this rare complication. Though surgeons may be averse to operate on haemophiliacs, primary surgical management as done in our case may prove to be the definitive treatment option for such patients.

Clear cell renal cell carcinoma with osseous metaplasia: Rare case report.

Osseous metaplasia with clear cell renal cell carcinoma (RCC) is exceedingly rare. There are less than 20 reported cases of osseous metaplasia in association with RCC. We present a case of 39-year-old male patient presented to outpatient department with complaints of pain in the left lumbar region since 4 years. Computed tomography scan revealed a heterogeneous enhanced mass lesion having areas of necrosis and specks of calcification involving the left kidney. Clinicoradiological diagnosis of RCC was made and left radical nephrectomy was performed. Histological sections from the growth revealed features of clear cell carcinoma Fuhrman grade-2 with a focal area of metaplastic bone formation. The prognostic implications of calcification per se are not very clearly mentioned in the literature. Patients with osseous metaplasia generally present with early stage disease and a favorable prognosis. However, few of them were of high grade and poorer prognosis.

Perforation peritonitis and the developing world.

Background. Perforation peritonitis is the one of the commonest emergency encountered by surgeons. The aim of this paper is to provide an overview of the spectrum of perforation peritonitis managed in a single unit of a tertiary care hospital in Delhi. Methods. A retrospective study was carried out between May 2010 and June 2013 in a single unit of the department of Surgery, Lok Nayak Hospital, Delhi. It included 400 patients of perforation peritonitis (diffuse or localized) who were studied retrospectively in terms of cause, site of perforation, surgical treatment, complications, and mortality. Only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included. Results. The commonest cause of perforation peritonitis included 179 cases of peptic ulcer disease (150 duodenal ulcers and 29 gastric ulcers) followed by appendicitis (74 cases), typhoid fever (48 cases), tuberculosis (40 cases), and trauma (31). The overall mortality was 7%. Conclusions. Perforation peritonitis in India has a different spectrum as compared to the western countries. Peptic ulcer perforation, perforating appendicitis, typhoid, and tubercular perforations are the major causes of gastrointestinal perforations. Early surgical intervention under the cover of broad spectrum antibiotics preceded by adequate aggressive resuscitation and correction of electrolyte imbalances is imperative for good outcomes minimizing morbidity and mortality.

Squamous cell carcinoma of the scrotum - still an occupational hazard.

Squamous cell carcinoma (SCC) of the scrotum was one of the first occupational diseases to be described, and acquired its eponym from Sir Percivall Pott. The condition has now become rare owing to the establishment of industrial health norms. A 45-year-old male with a history of long-term exposure to petrochemicals presented to our institution with a scrotal lesion and underwent wide-local excision of the same. Histopathology revealed well-differentiated SCC involving the epididymis. Treatment options included excision with ilio-inguinal bloc dissection (in the event of lymphadenopathy) with subsequent chemotherapy and/or radiotherapy. Tumors following occupational exposure thus continue to contribute to the rapidly decreasing incidence of scrotal carcinoma.

Pulmonary hydatid disease with coexistent aspergillosis: an incidental finding.

There are only a few case reports in the literature on the coexistence of aspergillosis and echinococcosis. We report a case of a 45-year-old immunocompetent patient who presented with a history of intermittent fever and cough with haemoptysis. Chest x-ray and CECT showed a large cystic lesion in right lower lobe with multiple floating membranes. Histopathological examination of cyst wall revealed the laminated membrane of hydatid cyst along with infiltration of its wall with septate fungal hyphae with acute angle branching suggestive of aspergillosis.

Psychosocial disorders in women undergoing postoperative radiation and chemotherapy for breast cancer in India.

BACKGROUND: Breast cancer is the most common cancer in urban India, but no study has been carried out on psychosocial disorders in breast cancer patients. AIMS: The present study has been undertaken to evaluate behavioural and psychosocial impacts before and after treatment of women with breast cancer. SETTINGS AND DESIGN: The study was carried out in a reputed hospital in Delhi. PATIENTS AND METHODS: A total of 97 breast cancer patients matched for age and economic status were divided into group A (66) and group B (31) on the basis of treatment modalities offered to the patient. These women were interviewed, before and after the treatment, and the observations were recorded in a pre-tested structured questionnaire. STATISTICAL ANALYSIS: Chi-square test and Fisher's exact test were used to calculate statistical significance. RESULTS: Although the extent of sociobehavioral disorders were higher in patients on postoperative adjuvant chemotherapy and radiotherapy when compared with those on postoperative adjuvant chemotherapy alone, the difference was, however, not statistically significant. Psychological reactions were observed in 31% of patients but after intervention, 65% showed adjustment within 4 to 12 weeks, whereas the rest showed late adjustments. CONCLUSIONS: Breast disfigurement and sexuality were found to be least important, but psychological and social support appears to significantly influence the treatment outcome and rehabilitation of breast cancer patients in India.

Evaluation of subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel in varicose veins: an observational study.

INTRODUCTION: Conventional modalities used to treat varicose veins with incompetent perforators and subsequent stasis ulceration have proved to be effective, however there are associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence. Recent advances have been made in minimally invasive vein surgery techniques to decrease operative morbidity, number and size of incisions, recovery time, and operative time. METHODS: A prospective study of 21 patients of varicose veins with incompetent perforators undergoing subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel was designed and various parameters were studied. RESULTS: All ulcers healed in 8 weeks with no recurrence in 11.9 months follow-up period. One case of wound infection and each saphenous nerve neuropraxia were the only postoperative complications noted. CONCLUSION: Use of ultrasonic scalpel in SEPS is technically feasible, causes less tissue damage as it generates a low thermal effect, and is associated with minimal morbidity.

Risk factors with breast cancer among women in Delhi.

BACKGROUND: The incidence of breast cancer is on the rise in India, breast cancer is the second most common malignancy in Indian women. AIM: The aim of this study was to find out the association of various risk factors with breast cancer among women in Delhi. SETTINGS AND DESIGN: This was a case-control study in Lok Nayak Hospital, Delhi. METHODS AND MATERIAL: 332 women were studied. Subjects were women with breast cancer (N = 115) and age matched Control subjects (N-217) without breast cancer, attending Lok Nayak Hospital during 2006. Subjects were interviewed using a pretested questionnaire. The risk factors studied were: age, parity, socioeconomic status, marital status, breast feeding, menarche, menopause, family history. STATISTICAL ANALYSIS: Data was expressed in proportion. RESULTS AND CONCLUSIONS: Age of the patient ranged from 25 to 80 years. In this study, 69 (60%) cases and 127 (58.5%) controls were illiterate, the mean duration sum of total breast feeding for all children was 6.58 years in cases and 7.4 years in controls (OR = 1.91; 95% CI, 1.17 - 3.13) (P P P< 0.05). There was a significant difference between breast cancer cases and controls in relation to place of residence, occupation, marital status, body mass index and breast feeding.

Video-assisted thoracoscopic decompression of tubercular spondylitis: clinical evaluation.

STUDY DESIGN: A prospective, observational study using a novel procedure of video-assisted thoracoscopy and conventional, long spinal instruments for decompression of dorsal tubercular spondylitis. OBJECTIVES: To assess the efficacy of video-assisted thoracoscopic decompression of dorsal tubercular spondylitis and compare it with the published data of classic thoracotomy procedures. SUMMARY OF BACKGROUND DATA: Surgical decompression of dorsal tubercular spine with the transpleural transthoracic method is a standard procedure. It is a major surgery with significant morbidity in terms of blood loss, intensive care unit (ICU) and hospital stay, postoperative incision pain, and chest tube insertion. A procedure that has the potential to achieve comparable recovery in patients with dorsal tubercular spondylitis but with a surgery of lesser magnitude and morbidity has immense potential. METHODS: There were 16 patients with mid-dorsal tubercular spondylitis with paraplegia/paraparesis requiring surgery who were included in the study. Every patient had a recent paradiscal disease at a single level. A soft tissue shadow was visible on plain radiographs of the spine, and conservative treatment for at least 3 weeks had shown no recovery. Patients with obvious respiratory insufficiency and likely to have significant pleural adhesions were excluded from the study. Single lung anesthesia and ipsilateral lung collapse using a double-lumen tube were administered. A 3-portal thoracoscopy approach was used, and conventional but long spinal instruments were used through an open port to decompress the spine. Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of chest tube insertion, ICU and hospital stay, and neurologic recovery. Patients were observed for a minimum of 6 months. RESULTS: Of 16 patients, 14 (88%) had good neurologic recovery. In 1 patient, thoracoscopy was abandoned, and open thoracotomy was performed because of persistent bleeding. Another patient did not recover, and anterolateral decompression was performed 10 weeks after thoracoscopy. She recovered subsequently. Other complications included fracture of the sixth rib in 1 patient and breakage of suction tip in another. Adequate tissue biopsy for histopathologic examination could be obtained in all patients. Duration of surgery was 223 minutes (+/-56), blood loss was 497 ml (+/-302), and blood transfusion was required in 3 patients (3 U in 1 and 1 U in 2). Postoperative analgesic (tramadol) was 243 mg (+/-70) for 2-4 days (median 3), median hospital stay was 5.5 days (range 4-9), chest tube requirement was 3 days (range 2-7), and 2 patients were required to stay in the ICU for 1 day each. CONCLUSION: Video-assisted thoracoscopic decompression of tubercular dorsal spondylitis is a viable option to achieve significant neurologic recovery with less morbidity, blood requirement, and hospital stay compared to the open thoracotomy procedures.

Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy.

BACKGROUND: The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy. METHODS: After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction. RESULTS: The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group (P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) (P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2-19 months). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.

Open port placement of the first laparoscopic port: a safe technique.

BACKGROUND: Blind insertion of the Veress needle and of the first trocar is a significant cause of complications in laparoscopic surgery. Despite this risk, the closed technique is still more popular than the open one. Our aim is to report the results of our experience with the routine use of the modified open technique in laparoscopic surgery and to describe the technical details of the creation of pnuemoperitoneum by the open technique that we used. METHODS: A prospective study was conducted in the department of surgery at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi. A modified method of open laparoscopy was performed on 755 consecutive patients requiring laparoscopy or laparoscopic surgery over a 5-year period from August 1998 to February 2003 in 1 surgical unit. RESULTS: The mean time taken was 4 minutes (range, 2 to 10). No intraoperative complications occurred during trocar insertion. Forty-nine (6.49%) patients had minor umbilical sepsis, 22 (2.91%) had periumbilical hematoma, but none had umbilical hernia during 3 months of follow-up after surgery. CONCLUSION: Based on our own experience, we recommend open laparoscopy as a safe and easy approach for routine laparoscopic interventions.

A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography.

A prospective study was conducted from March 1999 to April 2000 that included 73 patients who underwent elective laparoscopic cholecystectomy for uncomplicated gallstone disease. The study was conducted at one surgical unit in the Department of Surgery and Department of Radio-diagnosis and one surgical unit in the Department of Surgery, Maulana Azad Medical College and the associated Lok Nayak Hospital, which is the largest referral hospital in northern India and is located in the capital of India. A preoperative ultrasound was performed just prior to surgery, and 4 ultrasonographic parameters were analyzed. namely gallbladder wall thickness, contracted gallbladder, impaction of gallstones at the neck of the gallbladder, and common bile duct stones. The surgical findings were objectively graded as difficult or easy laparoscopic cholecystectomy according to 5 operative parameters, namely total time taken for the surgery, time taken to dissect gallbladder bed, spillage of stones, tear of gallbladder during dissection, and conversion to the open procedure. Of the 73 cases, 17 (23.3%) were conversions to the open procedure. Of the 21 (28.76%) cases predicted to be difficult, 17 (23.3%) were technically difficult, of which 13 (17.8%) were converted to the open procedure. Of the 52 (71.23%) cases predicted to be easy on ultrasonography, only 7 (9.38%) were found to be difficult on surgery, of which only 4 (5.48%) had to be converted to the open procedure. Based on our results, we conclude that preoperative ultrasonography is of great value in selecting patients preoperatively for laparoscopic cholecystectomy and minimizing complications and conversion to the open procedure.

Experiences with ESR (endolymphatic sac revascularization) in cases of sensorineural hearing-loss.

Experience based on 14 cases of severe-to-total sensorineural deafness, treated with endolymphatic sac revascularization, operation, is presented. Changes seen in the endolymphatic sacs and lateral sinuses of these patients have been detailed. Irrespective of the degree and duration of deafness, significant hearing gain (with good improvement in speech discrimination) was obtained in nine out of 14 cases (64.28 per cent). There was no improvement at all in one out of 14 (7.14 per cent), and there was a relapse of the hearing-loss two months post-operatively in one case (7.14 per cent). Tinnitus disappeared in the operated ear in three out of five cases (60 per cent) and vertigo improved considerably in four out of six cases (66.66 per cent). The follow-up in this series has been up to two years.