EPIDERMAL GROWTH FACTOR RECEPTOR (EGFR) POLYMORPHIC VARIATIONS (-216G/T & -191 C/A) POSE A HIGH RISK TO PATIENTS WITH MALIGNANT GLIOMA.

BACKGROUND: Malignant gliomas are the most frequent and lethal brain tumors. Their molecular aspects remain intangible but current studies have pointed to certain genetic polymorphic loci that pose the risk. The polymorphic sequence variations of the epidermal growth factor receptor gene (EGFR) pathway play a vital role in the glioma risk, and the EGFR variants (216G>T and 191C>A) are identified to affect the risk for the development of different tumors including glioma. AIM: To examine genetic variations of EGFR T rs712829 (216G/T) and rs712830 (191C>A) with respect to glioma risk. MATERIALS AND METHODS: 129 confirmed glioma cases were genotyped against 180 malignancy-free healthy controls by polymerase chain reaction-restriction fragment length polymorphism technique (RFLP). RESULTS: The frequency of the TT homozygous variant of the EGFR -216 G/T genotype differed significantly between cases and controls (49.6% vs. 23.0%) (p < 0.0001). The EGFR -216 G>T allele 'T' was found significantly more frequently in cases (0.56 vs. 0.33 in controls; p < 0.0001). The EGFR -191C>A homozygous 'AA' genotype was implicated significantly more frequently in cases than in controls (p < 0.0001). The distribution of the 'A' variant allele was also more frequent in cases (41.9%) than in controls (14.0%) (0.55 vs. 0.30; p < 0.0001). TC and TA haplotypes showed varied frequency in cases and controls. CONCLUSION: EGFR -216 G>T and -191 C>A variants and haplotypes (TA and TC) of the EGFR gene are very strong risk factors in the development of glioma in the Kashmiri population.

Evaluation of chromosome 1p/19q deletion by Fluorescence in Situ Hybridization (FISH) as prognostic factors in malignant glioma patients on treatment with alkylating chemotherapy.

BACKGROUND: Either deletion or co-deletion of chromosomal arms 1p or 19q is a characteristic and early genetic event in oligodendroglial tumors that is associated with a better prognosis and enhanced response to therapy. Information of 1p/19q status is now regarded as the standard of care when managing oligodendroglial tumors for therapeutic options in anticipation of the increased survival and progression-free survival times associated with it. Keeping this in view, we first time attempted to establish the FISH based detection of 1p/19q deletion in glioma tissue samples to evaluate its role and involvement in the disease. METHOD: Overall 39 glioma cases of different histologies were evaluated by fluorescence in situ hybridization (FISH) technique using specific FISH probes with Olympus BX43 fluorescent microscope to detect chromosomes 1p and 19q or co-deletions therein. RESULTS: Of the 39 glioma samples, overall 27 (69.2%) were found to have deletion either in 1p, 19q or both. Deletions were observed in 23.0%, 7.6% and 38.4% in 1p, 19q and 1p/19q co-deletions respectively. Overall oligidendrioglioma presented with 53.8% (21 of 39) deletions, astrocytoma group showed 12.8% and GBM accounted for 2.5% deletions. Overall survival and disease free survival was seen significantly better in oligidendrioglioma and astrocytoma with deleted tumors as compared to non-deleted ones (p<0.05). CONCLUSION: Allelic losses on 1p and 19q, either discretely or shared, were more frequent in classic oligodendrogliomas than in either astrocytoma or Glioblastoma with better survival and response to therapy.

Association of strong risk of hTERT gene polymorphic variants to malignant glioma and its prognostic implications with respect to different histological types and survival of glioma cases.

BACKGROUND: Germline genetic variants of human telomerase reverse transcriptase (hTERT) are known to predispose for various malignancies, including glioma. The present study investigated genetic variation of hTERT T/G (rs2736100) and hTERT G/A (rs2736098) with respect to glioma risk. METHODS: Confirmed cases (n = 106) were tested against 210 cancer-free healthy controls by the polymerase chain reaction-restriction fragment length polymorphism technique for genotyping. RESULTS: Homozygous variant 'GG' genotype of rs2736100 frequency was > 4-fold significantly different in cases versus controls (39.6% 17.2%; p < 0.0001). Furthermore, variant 'G' allele was found to be significantly associated with cases (0.5 versus 0.2 in controls; p < 0.0001). Homozygous variant rs2736098 'AA' genotype (35.8% versus 23.8%) and allele 'A' (0.49 versus 0.34) showed a marked significant difference in cases and controls, respectively (p < 0.05). In hTERT rs2736100, the GG genotype significantly presented more in higher grades and GBM (p < 0.0001). Furthermore, the GG variant of hTERT rs2736100 had a poor probability with respect to the overall survival of patients compared to TG and TT genotypes (log rank p = 0.03). Interestingly, two haplotypes of hTERT rs2736100/rs2736098 were identified as GG and GA that conferred a > 3- and 5-fold risk to glioma patients respectively, where variant G/A haplotype was observed to have the highest impact with respect to glioma risk (p < 0.0001). CONCLUSIONS: The results of the present study indicate that hTERT rs2736098 and rs2736100 variants play an important role in conferring a strong risk of developing glioma. Furthermore, hTERT rs2736100 GG variant appears to play a role in the bad prognosis of glioma patients. Haplotypes GG and GA could prove to be vital tools for monitoring risk in glioma patients.

Utility of Computed Tomography-guided Biopsy in Evaluation of Metastatic Spinal Lesions.

INTRODUCTION: Computed tomography (CT)-guided biopsy of spine is currently a valuable diagnostic tool and effective technique for diagnosing and planning a proper therapeutic strategy for certain spinal lesions. The reported diagnostic accuracy of core biopsy ranges from 77% to 97%. MATERIALS AND METHODS: We included all patients with spinal lesions suspicious of metastasis on magnetic resonance imaging, who presented between May 2012 and April 2014 and underwent CT-guided biopsy in our study. A total of thirty patients with spinal lesions were evaluated. RESULTS: Majority presented in the seventh decade of their life (average age = 53.93; age range = 10-72 years). Male:female ratio was 1.5:1. Pain was the most common presenting symptom (100%). Lumbar spine was the most common site of lesion followed by dorsal spine. Biopsy is the gold standard in histopathological evaluation of spinal lesions. Metastatic lesion was diagnosed in 12 (40%) cases, plasmacytoma in 12 (40%) cases, non-Hodgkin's lymphoma in 2 (6.66%) cases, small round cell tumor in 1 (3.33%) case, nonspecific chronic inflammation in two patients, and necrosis with no viable cells in one patient. The most common malignancy to metastasize to spine was adenocarcinoma. The most common primary tumor of spine was plasmacytoma - multiple myeloma. CONCLUSION: CCT-guided biopsy is a safe procedure, and no procedure-related complication was seen in any patient.

Concordant association validates MGMT methylation and protein expression as favorable prognostic factors in glioma patients on alkylating chemotherapy (Temozolomide).

O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation and its subsequent loss of protein expression has been identified to have a variable impact on clinical outcome of glioma patients indicated for chemotherapy with alkylating agents (Temozolomide). This study investigated methylation status of MGMT gene along with in situ protein expression in malignant glioma patients of different histological types to evaluate the associated clinical outcome vis-a-vis use of alkylating drugs and radiotherapy. Sixty three cases of glioma were evaluated for MGMT promoter methylation by methylation-specific PCR (MS-PCR) and protein expression by immunostaining (IHC). Methylation status of MGMT and loss of protein expression showed a very high concordant association with better survival and progression free survival (PFS) (p < 0.0001). Multivariate Cox regression analysis showed both MGMT methylation and loss of protein as significant independent prognostic factors in glioma patients with respect to lower Hazard Ratio (HR) for better OS and PFS) [p < 0.05]. Interestingly concordant MGMT methylation and lack of protein showed better response in TMZ therapy treated patient subgroups with HR of 2.02 and 0.76 (p < 0.05). We found the merits of prognostication of MGMT parameters, methylation as well as loss of its protein as predictive factors for favorable outcome in terms of better survival for TMZ therapy.

ACE I/D sequence variants but not MTHFR C677T, is strongly linked to malignant glioma risk and its variant DD genotype may act as a promising predictive biomarker for overall survival of glioma patients.

OBJECTIVE: ACE I/D and MTHFR C677T gene polymorphisms can be seen as candidate genes for glioma on the basis of their biological functions and their involvement in different cancers. The aim of this study was to analyze potential association and overall survival between MTHFR C677T and ACE I/D polymorphism in glioma patients in our population. MATERIALS AND METHODS: We tested genotype distribution of 112 glioma patients against 141 cancer-free controls from the same region. Kaplan-Meier survival analysis was performed to evaluate overall survival of patients for both genes. RESULTS: No significant differences were found among MTHFR C677T wild type C and variant genotypes CT/TT with glioma patients. In ACE, the distribution of variant ID and DD was found to be significantly higher in glioma cases as compared to controls (p<0.0001). ACE DD genotypes were highly presented in glioma cases 26.8% versus 10.6% in controls (p<0.0001) and conferred 5-fold risk for predisposition in glioma cases. Per copy D allele frequency was found higher in cases than in controls (0.54 versus 0.25: p<0.0001). Interestingly we found a significant overall survival (with log rank p<0.01) in patients who presented with ACE DD genotypes had the least estimated overall survival of 13.4months in comparison to 21. 7 and 17.6months for ACE II and I/D genotypes respectively. CONCLUSION: We conclude ACE I/D polymorphism plays a vital role in predisposition of higher risk for glioma. We also suggest that ACE DD genotypes may act as an important predictive biomarker for overall survival of glioma patients.

Diagnostic value of Tzanck smear in various erosive, vesicular, and bullous skin lesions.

BACKGROUND: Cutaneous cytology has long been shown to be useful in the diagnosis of several erosive, vesicular, and bullous skin lesions. The Tzanck smear although an old tool, still remains a simple, rapid, easily applied, and inexpensive test for these skin lesions. AIMS AND OBJECTIVES: The aim of this study was to evaluate the diagnostic value of Tzanck smear by determining its sensitivity and specificity in various erosive, vesicular, and bullous skin lesions. MATERIALS AND METHODS: One hundred and forty-two patients with erosive, vesicular, and/or bullous skin lesions were included in the study. Four groups of disorders were identified: infections, immunologic disorders, genodermatosis, and spongiotic dermatitis. All the study cases were evaluated by Tzanck smear. Definitive diagnosis was established by standard diagnostic techniques (including when appropriate, viral serology, bacterial culture, histopathology, direct immunoflourescence). RESULTS: The sensitivity and specificity of cytologic findings was respectively 86.36% and 91.30% for viral infections; for bacterial infections, it was 85.7% and 66.6%. The sensitivity and specificity of Tzanck smear was respectively 85.0% and 83.33% for pemphigus; for bullous pemhigoid it was 11.11% and 100.0%. Tzanck smear sensitivity in genodermatoses was 100%. The sensitivity and specificity of the test in spongiotic dermatitis could not be calculated due to an insufficient number of patients. CONCLUSION: The Tzanck smear is a quick and reliable tool for the evaluation of various erosive and vesiculobullous skin lesions.

A selective approach to the surgical management of periampullary cancer patients and its outcome.

BACKGROUND: Pancreaticoduodenectomy is a high risk, complex, technically challenging operation associated with significant perioperative morbidity and mortality. This study on the surgical management of periampullary cancer patients is based on our experience in a period of nearly 13 years. METHODS: The study was conducted on two groups of patients: group A included 42 patients who were treated between January 2000 and September 2005 and group B included 134 patients who were treated between October 2005 to October 2012. Preoperative, intraoperative and postoperative details of all these patients were collected, tabulated and analyzed to assess the impact of the selective approach introduced in the department with effect from October 2005. RESULTS: Intraoperative details revealed highly significant differences in the management of the two groups of patients in respect of operative time (250.4 vs 126.6 minutes; P<0.001), operative blood loss (1070.2 vs 414.9 mL; P<0.001) and intraoperative blood transfusion (1.4 vs 0.2 units; P<0.001). Variations between the two groups in the frequency of complications were found to be statistically insignificant. However, the difference between the two groups in the overall morbidity of patients (47.6% vs 26.1%; P=0.009) and the length of their hospital stay (11.8 vs 7.8 days; P<0.001) were significant. CONCLUSION: A selective approach applied to the surgical management of periampullary cancer patients is a step in the right direction.

MGMT gene silencing by promoter hypermethylation in gastric cancer in a high incidence area.

PURPOSE: Inactivation of tumor suppressor and DNA repair genes by promoter hypermethylation does commonly occur in human cancers. O(6)-methylguanine-DNA methyltransferase (MGMT) is a DNA repair enzyme that removes methyl groups as well as larger adducts at the O(6) position of guanine. In the absence of MGMT activity, O(6)-methylguanine mispairs with thymine during DNA replication, resulting in G:C to A:T transitions. Promoter hypermethylation of the MGMT gene has been observed in various cancers, including gastric cancer. Here, we aimed at assessing the promoter hypermethylation, mutation and expression status of the MGMT gene in patients from a geographic region with a high incidence of gastric cancer (Kashmir, North India) and to investigate their association with various clinicopathological characteristics. METHODS: In this study 82 gastric cancer samples and adjacent normal tissues were included. Mutations in the MGMT gene were detected by single stranded conformational polymorphism (SSCP) analysis and direct sequencing. Methylation-specific polymerase chain reaction (MS-PCR) and Western blot analyses were performed to detect promoter hypermethylation and concomitant (loss of) expression of the MGMT gene. RESULTS: Promoter hypermethylation of the MGMT gene was found in 52.44% (43 of 82) of the tumor samples and loss of MGMT protein expression was detected in 45.12% (37 of 82) of the tumor samples. Hypermethylation and loss of expression were significantly associated with higher tumor grades (moderately/poorly differentiated) (P < 0.05) and higher tumor stages (III/IV) (P < 0.05). In addition, MGMT hypermethylation and loss of expression were found to be significantly associated with high salt tea consumption (P < 0.05). CONCLUSIONS: Our results indicate that MGMT promoter hypermethylation and concomitant loss of MGMT protein expression may play an important role in the development of gastric cancer in the Kashmiri population. High salt tea consumption may be a risk factor.

Metastatic lymphadenopathy in Kashmir valley: a clinicopathological study.

BACKGROUND: Lymphadenopathy is a common presentation in both benign and malignant diseases which need to be diagnosed without delay. Fine needle aspiration cytology (FNAC) helps us diagnose a disease and follow its course, including the response to therapy. AIM: This study aimed to analyze the clinicopathological features of metastatic lymphadenopathy and the diagnostic utility of FNAC in our setting. MATERIALS AND METHODS: This two-year prospective study included all the patients with metastatic lymphadenopathy, diagnosed with FNAC. RESULTS: A total of 412 cases (male:female ratio, 1.3:1; age range, 3 to 90 years) were studied. Supraclavicular lymph nodes were involved most commonly (50.5%). The commonest metastatic tumor was squamous cell carcinoma in general (30.1%) and in males (37.6%), and infiltrating ductal carcinoma (25.3%) in females. Lung, with 64 (15.5%) cases followed by esophagus, 60 (14.6%) cases; breast, 49 (11.9%) cases; skin, 32 (7.8%) cases; and stomach, 25 (6.1%) cases were the most common primary sites of malignancy. In 69 patients, excision biopsy was performed. Histopathological findings correlated well with that of cytology in all these cases. CONCLUSIONS: FNAC is an important tool in the diagnostic work up of metastatic lymphadenopathy, which in the hands of an experienced and skilful cytopathologist can avoid the need for excision biopsy.

Cystic dilatation of the cystic duct: a type 6 biliary cyst.

Choledochal cysts of the cystic duct are extremely unusual and only single case reports are documented in the literature. The widely used Todani classification does not include such type of lesions. We present a case of a young girl with a cystic duct choledochal cyst diagnosed preoperatively and confirmed intraoperatively. Due to the site and mass effect of the cyst, excision of the lesion included a part of bile duct. Reconstruction was achieved by Roux-en-Y hepaticojejunostomy. While such lesions are extremely rare, they do occur and need to be recognized as a separate entity in the Todani classification.

Left-sided hepatic resection for hepatolithiasis: a longitudinal study of 110 patients.

BACKGROUND: Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis. METHODS: One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined. RESULTS: Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3-134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones. CONCLUSIONS: This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.

Profile of lymphadenopathy in Kashmir valley: a cytological study.

Lymphadenopathy is one of the commonest and significant manifestations of local as well as systemic ailments, especially malignancies. Fine needle aspiration cytology (FNAC) helps in diagnosing the disease itself, in general, but more importantly ruling out malignancy, in particular. Hence it saves much of the cost and use of resources incurred with excision biopsy of such lymph nodes. This prompted us to study the cytologic patterns of lymphadenopathy in our setting and the diagnostic utility of FNAC in the evaluation of lymphadenopathy. In this retrospective observational study, 1,579 patients (953 males and 626 females) with lymphadenopathy who were subjected to FNAC over a period of three years (January 2009 to December 2011) were studied. The cervical region was involved in most of the cases (76%) followed by the axillary region (17.5%). Metastatic malignancy (38.2%) was the commonest cause of lymphadenopathy followed by reactive lymphoid hyperplasia (36.9%), tuberculosis (9.1%) and lymphomas (8.6%). Squamous cell carcinoma (32.2%) followed by adenocarcinoma (21.9%) were the most frequent metastatic tumors. FNAC is a useful diagnostic tool in the management of patients presenting with lymphadenopathy and should be considered before more invasive and costly procedures are performed, particularly in developing countries.

Hydatid cyst of the pancreas. An experience with six cases.

CONTEXT: The pancreas is an infrequent site of hydatid disease. OBJECTIVE: This study aims at giving better insight into the diagnostic and managerial approach to the disease. PATIENTS: Six patients with hydatid cysts of the pancreas. DESIGN: Retrospective review of the clinical records. RESULTS: The six patients (four men, two women) ranged in age from 18 to 68 years. Five of the cysts were primary while one had an associated cyst in the liver. Abdominal pain, vomiting, abdominal mass and dyspeptic symptoms were seen in cysts involving the body and tail. Two patients having cysts in the head of the pancreas presented with obstructive jaundice. An indirect hemagglutination test and an enzyme-linked immunoabsorbent assay were positive for the presence of specific hydatid antibodies in four patients. Abdominal ultrasonography, computed tomography and magnetic resonance cholangiopancreatography (MRCP) successfully imaged the cysts and also defined the relationship of the lesion with the pancreatic duct. All patients underwent surgical exploration. Three patients had intraoperative fine needle aspiration cytology of the cystic lesion for microscopic and electrolyte analysis. A preoperative diagnosis was possible in two patients and, in the other four, the diagnosis was made intraoperatively and confirmed on histopathological examination. PATIENTS: with cysts located in the tail underwent a distal pancreatectomy with a splenectomy while those with cysts in the body had a pericystectomy or central pancreatectomy. Cysts of the head were treated with evacuation, partial cystectomy and tube drainage. There were no postoperative complications, and no evidence of cyst recurrence was observed during the follow-up period. All the patients were followed up at three-month intervals with a mean follow-up time of 58.7 months (rang: 4-120 months); no patient had cyst recurrence or dissemination. CONCLUSION: A hydatid cyst is an uncommon cause of cystic lesions in the pancreas and should be included in the differential diagnosis of cystic lesions of the pancreas, especially in endemic areas. Intraoperative fine needle aspirate for microscopic and electrolyte estimation seems to be an effective method for establishing a proper diagnosis. MRCP, which can depict the communication of the cystic lesion with the pancreatic duct, helps in defining the type of surgical treatment. Cysts in body and tail are best treated by resectional methods whereas, for those in the head region, a cystectomy with simple drainage is a simple, quick and effective solution.

Hepaticocholecystoduodenostomy compared with Roux-en-y choledochojejunostomy for decompression of the biliary tract.

BACKGROUND AND OBJECTIVES: The nature of palliative decompressive surgery for unresectable periampullary tumor is usually determined by the experience of the surgeon. We compared hepaticocholecystoduodenostomy (HCD), a new palliative decompressive anastomotic technique, to Roux-en-y choledochojejunostomy (CDJ) in this prospective, randomized study. PATIENTS AND METHODS: Twenty patients who were to undergo surgery for palliative bypass were randomized into two groups: group I was subjected to HCD (10 patients) and group II to CDJ (10 patients). Pre- and postoperative liver function tests, operative time, operative blood loss, onset of postoperative enteral feeding, length of hospital stay and survival rates were compared in the two groups. RESULTS: Effective surgical decompression was observed clinically as well as on analysis of pre- and postoperative liver function tests in both the groups. The results were statistically significant in favor of patients in group I when compared to those of group II with respect to operative time 84.7 (10.3) min vs 133.6 (8.9) min; P =<.0001), operative blood loss 137.8 (37.2) mL vs 201.6 (23.4) mL; P =.001), postoperative enteral feeding 3.3 (0.5) days vs 5.0 (0.7) days; P =<.0001) and length of hospital stay 7.5 (0.7) days vs 9.7 (1.2) days ; P =<.0001). During follow-up, recurrent jaundice was observed in one patient in group I and two patients in group II, while duodenal obstruction developed in one patient in the group I series. Gastrointestinal hemorrhage occurred in one patient belonging to group II. The difference in mean survival time was not statistically significant. CONCLUSION: Based on this small series, HCD seems to be a better palliative surgical procedure than the routinely performed CDJ.

Choledochal cysts in children and adults with contrasting profiles: 11-year experience at a tertiary care center in Kashmir.

BACKGROUND: Choledochal cyst is a surgical problem usually related to infancy and childhood. Despite advancements in management, a large number of cases still present during adulthood. The clinical course and outcome in children varies from that in adults. This study focuses on these variations in terms of presentation, management, histopathology, and outcome. METHODS: An in-depth retrospective analysis was carried out on 79 patients presenting with choledochal cysts between December 2007 and January 1997. The patients were segregated into two groups: group A comprising 32 children and group B with 47 adults. The presentation, clinical evaluation, radiologic, and biochemical findings; operative details; pathologic findings; and early and long-term complications in the two groups were studied on a comparative basis. RESULTS: The male/female ratios were 1:3 and 1.0:2.3 in groups A and B, respectively. A history of previous biliary surgery, pancreatitis, cholangitis, peroperative difficulties, and early and late postoperative complications were 5.1, 5.4, 6.4, 5.4, 2.0, and 3.3 times more common in group B than in group A. However, the classic triad of jaundice, abdominal pain, and a mass was 6.7 times more common in group A than in group B. The classic triad and cholangitis were the only parameters that were statistically significant. Rare presentations of spontaneous perforation of the cyst or cachexia manifested only in group A patients. The methods of detection and operative treatment were identical for both groups. Histologically, fibrosis of the cyst wall was a feature peculiar to group A, whereas signs of inflammation and hyperplasia were predominantly seen in group B. In the group B series, one patient had cholangiocarcinoma and another gallbladder carcinoma; one more patient developed malignancy during follow-up. Long-term complications were seen in 29.7% of patients in group B versus 9.3% in group A; the most rampant complication was a type IVa cyst, seen in 68.7% of patients. CONCLUSIONS: Choledochal cysts present differently in adults and children; whereas children present with the classic triad, adults present with common biliary or infective complications. Although the methods of detection and surgical treatment are similar for the two groups, the type IVa cyst typically seen in the adult group creates a marked deviation with respect to long-term complications such as ascending cholangitis, anastomotic strictures, stone formation, and development of cholangiocarcinoma. These are areas of grave concern that can be addressed to a large extent by providing an access loop during the initial surgery especially for type IVa cysts. The glaring differences in terms of presentation, histologic picture, and outcome urges us to consider choledochal cysts in children as a separate entity.

Anthropometry and body composition of school children in Bahrain.

BACKGROUND AND OBJECTIVES: This study was conducted because of the lack of a comprehensive nationwide assessment of data on the anthropometric status and related health problems in Bahraini school children aged 6 to 18 years. SUBJECTS AND METHODS: A cross-sectional survey was conducted on the anthropometric status of school children enrolled in the primary, intermediate and secondary government schools in all populated regions of Bahrain. The sample size included 2594 students (1326 girls and 1268 boys) representing 2.5% of the total student population. For sample selection, a multi-stage sampling design was chosen that combined multi-cluster and simple random sampling methods. Anthropometric measurements included height, weight, mid-arm circumference and skin fold thickness at two sites (triceps and subscapular). Anthropometric indices derived were body mass index (BMI) and arm muscle area. The WHO reference standards (2007) and the National Health and Nutrition Examination Survey (NHANES) II data were used for comparison. RESULTS: Compared to WHO reference standards, the median height of Bahraini children and adolescents in the age range of 6 to 18 years was close to the 25th percentile or lower, while the median BMI during adolescent years was comparable in boys, but higher than WHO standards in girls, reaching the 75th percentile. The cutoff values of BMI for overweight/obesity status (85th and 95th percentile) were higher by 3-6 kg/m(2) compared to WHO standards. While skin fold thicknesses were also higher in Bahraini adolescents compared to their American counterparts (NHANES II), arm muscularity was substantially lower. CONCLUSIONS: Current study findings for BMI as well as skin fold thicknesses suggest an increased trend toward adiposity among Bahraini adolescents, especially in girls, which puts this age group at a high risk of adult obesity and its consequences. A need for urgent intervention programs is emphasized.

Clinicopathological study of male breast carcinoma: 24 years of experience.

BACKGROUND AND OBJECTIVES: Because breast cancer in men is rare, few patients are available for prospective studies. To learn more about its epidemiology, risk factors, clinical features, genetics and pathology in our country, we conducted a retrospective study of all cases seen in recent decades at our institution. PATIENTS AND METHODS: We identified each case of male breast cancer in the database at the Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India, between the years 1983 to 2007. RESULTS: We identified only 32 cases of male breast cancer over the 24-year period. Male breast cancer accounted for 32 (2.8%) of 1141 resected breast specimens, which included all breast lesions and 32 (4.1%) of 780 breast cancer cases. Of the 32 cases, 20 (62.5%) had various associated risk factors. Invasive ductal carcinoma was seen in 30 cases (93.7%). Of 20 cases that underwent molecular studies, 16 (80%) patients had estrogen receptor positivity whereas 14 (70%) had progesterone receptor positivity. Six cases (30%) overexpressed HER2 and p53. The BRCA2 mutation was observed in 4 cases (40%) while no patient presented with the BRCA1 mutation. CONCLUSION: An incidence of 4.1% for male breast cancer indicates that this disease is not as uncommon as presumed in this part of the world. Breast cancer in men seems more frequently to be hormone receptor positive and the BRCA2 mutation confers a significant risk to men.