Deborshi Sharma

Apoptosis: A Basic Physiologic Process in Wound Healing

Apoptosis, or programmed cell death, is a complex network of biochemical pathways for controlling such events in a cell. Apoptosis is essential, as its failure can lead to disease. Because apoptosis concerns the regulation of sequential events, including the removal of inflammatory cells and the evolution of granulation tissue into scar tissue, it has an essential role in wound repair. This article examines the literature and proposes that apoptosis features in the development of diabetic foot wounds. Hyperglycemia deregulates the sequential apoptotic events by multiple mechanisms, leading to delayed wound healing. Deregulated apoptosis is emerging as a prominent cause of delayed wound healing, especially in diabetic wounds, along with the well-known triad of peripheral vascular disease, neuropathy, and infection.

Malignant transformation of a pilonidal sinus

A 52-YEAR-OLD MAN presented with complaints of pain and an ulcerated tumor in the natal cleft. The patient had noted a discharging pit in the natal cleft for 20 years. It had developed into a small ulcer 1 year previously. The ulcer progressively increased, and at presentation was an 8 3 10 cm fungating tumor with pigmented margins and everted edges. It extended to the anal verge (Fig 1). The ulcer base was indurated and fixed to the underlying structures. Digital rectal examination was unremarkable. An incisional biopsy revealed welldifferentiated squamous cell carcinoma. Wide local excision of the tumor including the coccyx was performed with primary closure of defect. The anal sphincter and the anal verge were free of tumor. Histopathology confirmed well-differentiated squamous cell carcinoma (Fig 2) with margins free of tumour. The coccyx was infiltrated with tumour. The patient received adjuvant radiotherapy and is asymptomatic and free of recurrence at 12 months. DISCUSSION Pilonidal disease is a common condition affected 1.1% of the male population (10 times more common in males). The term pilonidal, meaning nest of hair, was coined in 1880 to describe defects occurring in the natal cleft characterized by a cutaneous sinus tract, which generally contains hairs. Pilonidal sinuses are most commonly believed to be acquired rather than congenital. Infection and abscess are common complications. Malignant transformation, most commonly to squamous cell carcinoma, although very rare, has been reported in about 60 cases. The ongoing Fig 1. Clinical photograph showing a fungating growth (8 3 10 cm) over the natal cleft. This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration.

Electrophoretic pattern of proteins in carcinoma of the gallbladder

Carcinoma of the gallbladder is a common health problem in the northern region of India and in spite of improved diagnostic techniques it is generally diagnosed at an advanced stage. This study was carried out in 60 patients, 30 of whom were diagnosed with gallbladder carcinoma and 30 with cholelithiasis. The protein content in tissue extracts and serum was determined using the Folin method of Lowry. Sodium dodecyl sulphate-polyacrylamide gel electrophoresis was performed for the identification of proteins according to Laemmli. The results showed the mean concentration of total protein in gallbladder tissue of patients with carcinoma of the gallbladder was 51.83±3.36 mg/g tissue (45.33–57.80) and in patients with cholelithiasis it was 38.82±9.11 mg/g tissue (29.55–50.99) (P<0.001). Protein electrophoresis of gallbladder tissue from the patients with carcinoma of the gallbladder showed three additional bands of protein (two protein bands were present in the region of 50–55 kDa and the third band was present in the region of 35 kDa), which were absent in the gallbladder tissue of cholelithiasis patients. Mean total protein content in serum was 72.2±1.73 g/l (67.98–74.99) in patients of carcinoma of the gallbladder, whereas it was 71.01±3.4 g/l (60.00–78.99) (P>0.05) in the patients with cholelithiasis. Electrophoretic analysis of serum protein revealed at least two additional protein bands in patients with carcinoma of the gallbladder as compared with electrophoretic pattern in cholelithiasis. These two bands were in the range of 80 and 25 kDa proteins. In conclusion, the presence of these new bands of protein in the gallbladder tissue and serum of the patients with carcinoma of the gallbladder indicate their role in the pathogenesis of the carcinoma of the gallbladder.

Primary rectal teratoma

A 14-year-old female presented with one episode of bleeding per rectum. Her general and physical examination was unremarkable except that a hard pedunculated polyp was palpated in the rectum about 7 cm from the anal verge. The mass was non-tender, had a slightly irregular surface and could be pulled near to the anal opening. There was no bleeding on touch. Under general anesthesia, rectal examination was done which revealed a 7 5 cm polyp covered with hairs, deliverable through the anal opening (Fig 1). The mass had a variegated consistency and was attached to the anterior rectal wall by a small stalk. Polypectomy was done with suture trans-fixation of the stump at the base. The cut surface of the mass revealed components from all layers of development (Fig 2). On histopathological examination the tumor was lined by mature stratified squamous epithelium with numerous pilosebasecous units scattered underneath. The substance of the polyp was predominantly composed of fibroadipose tissue. Attenuated colonic mucosa with thinned out muscularis propria could be identified at the edge. These findings were consistent with a mature teratoma (Fig 3).

Retrorectal dermoid cyst in an adult.

A 35-year-old woman presented with occasional rectal fullness and painful defecation for 6 months. She had no abnormality in her general and physical examinations except on her per rectal examination, where a smooth firm non-tender mass with an illdefined border was palpated posterior to the rectum. Ultrasonography of the pelvis showed a multiloculated cyst of approximately 8 cm · 7 cm. Contrast-enhanced computed tomography (CT) showed a thin-walled multilocular, nonenhanced 10 cm · 8 cm cyst in the retrorectal space (Fig. 1). CT shows low attenuating (fat density) areas in the periphery of the mass. Fat planes between the rectum and cyst were preserved. Plain bony radiograph of the pelvis showed no abnormality. Patient underwent laparoscopic mobilization of the rectum with removal of the cyst. Intraoperatively, the cyst had ruptured; hence a drain was put for 2 days in the retrorectal space. The cyst had approximately 100 mL of muddy material. Histopathological examination of the cyst wall showed a stratified squamous epithelium consistent with a dermoid cyst. The patient recovered well and is free of disease after 12 months of follow up. Developmental cysts, although very rare, can occur in the retrorectal region.1 Moreover, they rarely present in adult life, as they are of congenital origin.1 The various types include epidermoid, dermoid, neurenteric and enteric cysts. Enteric cysts can again be of two types: tail-gut cysts (hamartomas or mucin-secreting cysts) and cystic rectal duplication cysts.2 Clinical presentation of retrorectal cyst is variable, depending on the size and is often related to local compression of the rectum and the lower urinary tract.3 Most often, they are diagnosed in a routine clinical examination2,3 and may present with complications like infection, bleeding and malignant degeneration.2 Imaging reports are limited for retrorectal cysts. Plain radiography may show a bony defect in the sacrum whereas a contrast enema will show widening of the retrorectal space on a lateral view. On ultrasonography, the cyst appears uniloculated or multiloculated with internal echoes. CT shows a well-marginated, thin-walled, uniloculated or multiloculated, hypoattenuating, non-enhancing mass, rarely with thin calcifications. Magnetic resonance imaging gives high signal intensities on T1-weighted images secondary to fatty content,2 whereas chemical shift diffusion and weighted magnetic resonance imaging are useful in the diagnosis of dermoid cyst with little evidence of calcification and fat.4 Presacral masses are known to present as a part of Currarino triad along with anorectal malformation and sacral bony abnormality.5 It is specifically seen in the paediatric age group.5 Cystic sacrococcygeal teratomas, anterior sacral meningocoele, anal duct or gland cysts and rectal leiomyosarcoma can also rarely present as a presacral mass, whereas an associated abnormality of the genito-urinary system should always be considered.2 Complete excision of epithelial lining of the cyst has to be carried out preferably through an anterior (abdominal approach) or posterior approach.2,6 Recurrence and malignant transformation is a distinct possibility.2