Gunjan Desai

Primary neuroendocrine carcinoma breast: Our experience

OBJECTIVES This retrospective study was designed to present the clinical characteristics and histopathological features of Primary neuroendocrine carcinoma (PNEC) of breast, and to evaluate the impact on outcome following its management on the line of more common primary adenocarcinoma of breast. MATERIALS AND METHODS Records of four patients diagnosed with PNEC of breast were retrospectively reviewed. Data were obtained from medical record from January 2008 to December 2012. Diagnosis of PNEC was confirmed by histopathological examination (HPE) and immunohistochemical (IHC) staining of tissue obtained from Trucut biopsy of the breast lump in all four patients. PNEC of breast was defined by the presence of more than 50% of invasive tumor cells with cytoplasmic immunoreaction for neuroendocrine (NE) markers synaptophysin, chromogranin or neuron specific enolase as per WHO classification. All patients were treated with Modified Radical Mastectomy (MRM), six cycle of Cyclophosphamide, Adriamycin and 5-Flurouracil (CAF) based adjuvant chemotherapy, radiotherapy and hormonal therapy. RESULTS There were four female patients. The mean age was 58~years (50-65 years). Breast lump was the presenting complaint in all patients. The result of HPE showed tumor size ranging from 4 to 6.5 cm in diameter. Axillary lymph node metastasis was detected in three (75%) patients. ER and PR expression was positive in four (100%) and three patients (75%) respectively. None of the patients expressed Her-2-neu. IHC staining was positive for NE markers chromogranin in three (75%) patients, synoptophysin in two patients (50%) and Neuron specific enolase three (75%) patients. The mean follow-up time was 27.7 months (range 48-9). All four patients survived without any loco-regional or metastatic recurrence with one patient developing lymphedema of arm. CONCLUSIONS Breast lump is the most common presentation of PNEC of the breast with characteristic expression of NE markers by the tumor. Management of this rare tumor may include surgery, chemotherapy, radiotherapy and hormonal therapy depending on the size of the tumor, lymph node and hormone receptor status. However, most appropriate treatment plan has yet to be established.

AMYAND’S HERNIA: OUR EPERIENCE AND REVIEW OF LITERATURE

When a normal, inflamed or perforated appendix is found as a content in an incarcerated inguinal hernia, it is called the Amyand’s hernia1. The incidence varies from 0.19-1.7% of reported hernia cases2. Appendicitis in Amyand’s hernia is believed to be caused by extra luminal compression and can mimic appendicitis or complicated inguinal hernia. Since both inguinal hernia and acute appendicitis are clinical diagnosis, a preoperative radiological diagnosis is usually not available3. The clinical importance lies in the fact that it can result in various complications due to delayed diagnosis and mortality has been reported in range of 6-15%3,4. The most important determinant of treatment is the presence or absence of appendicitis and periappendiceal abscess5. Use of mesh is traditionally contraindicated in cases of an inflamed or perforated appendix. However, case series have been published with mesh repair, mainly due to the availability of potent antibiotics and biological meshes6,7. We here present our experience of three diverse cases of Amyand’s hernia and review its present literature in brief.

Clinico-epidemiological profile of breast cancer patients and the retrospective application of Gail model 2: An Indian perspective.

AIM To study the clinical and epidemiological profile of patients of breast cancer presenting at our center at New Delhi, India and to evaluate the applicability of Gail model 2 as a means of measuring 5-year and lifetime risk in our already diagnosed cases of breast cancer. METHODS This was a retrospective study conducted at Lady Hardinge Medical College Hospital in New Delhi, India, between January 2011 and July 2014. Two hundred and twenty two diagnosed cases of breast cancer were included. Information was collected retrospectively on a Performa from the medical record section and the Pathology department of the hospital.The predicted five-year and lifetime risk was calculated using GM2 prediction model from the NCIs breast cancer risk assessment tool website. RESULTS AND CONCLUSIONS Breast cancer in India is a far more biologically aggressive disease than in the west with a widely different spectrum of presentation and behavior and late presentation in an advanced stage. The accepted risk factors routinely associated with breast cancer in western literature do not appear to be relevant in the Indian population. Accepted western models do not seem to apply in the Indian scenario.

Appendicular perforation in dengue fever: our experience

Abstract Dengue viral infections have become one of major emerging infectious diseases in the tropics. Acute abdomen occurring in dengue viral infection is not uncommon. The spectrums of acute surgical emergencies which raise suspicion of an abdominal catastrophe in patients presenting with dengue fever include acute pancreatitis, acute acalculous cholecystitis, non-specific peritonitis and very rarely acute appendicitis. The presence of low white cell count and platelet count can raise suspicion of a diagnosis of dengue in a patient presenting with acute abdominal pain, during a dengue epidemic. We herein report three patients with dengue fever who had appendicular perforation during the course of their viral fever.

Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: Is it olde worlde?

OBJECTIVE This article aims to identify the patient selection criteria and approach in treating persistent external pancreatic fistulas surgically with Roux-en-Y fistulojejunostomy, and it evaluates the outcomes of Roux-en-Y fistulojejunostomy with a review of the relevant literature. MATERIAL AND METHODS A retrospective data analysis from January 2010 to May 2017 revealed 6 patients who were managed with Roux-en-Y fistulojejunostomy for persistent external pancreatic fistulas, and their details were entered in a proforma. Standard surgical steps were performed in all patients, and the patients were followed up postoperatively for 1 year. Data were analyzed for outcomes, and the literature was reviewed. RESULTS Four of 6 patients had persistent external pancreatic fistulas following pancreatic necrosectomy, 1 had surgery for pancreatic pseudocyst, and 1 after pancreaticoduodenectomy for pancreatic head mass. An average duration of conservative management was 14 weeks, and Roux-en-Y fistulojejunostomy was performed at a median distance of 6 cm from pancreas via a midline laparotomy. All patients recovered without major complications. Only 1 patient developed diabetes at a 1-year follow-up. CONCLUSION Fistulojejunostomy is a safe and effective treatment for persistent pancreatic fistula having the benefit of avoiding a difficult major pancreatic resectional surgery in an already debilitated patient with frozen tissue planes, along with low postoperative morbidity and mortality. The short- and mid-term outcomes in the literature for this procedure are good, as it has also been seen in our study on diverse indications.

Pancreaticoduodenectomy with Replaced Common Hepatic Artery and Portal Vein Reconstruction in Primary Carcinoma Duodenum: a Case Report and Literature Review.

The role of combined arterial and superior mesenteric-portal venous resection and reconstruction is not established in primary duodenal carcinoma [1, 2]. Arterial resections tend to result in high morbidity [2]. We present here a case of primary duodenal carcinoma wherein a combined vascular resection and primary repair was performed, along with the possible selection criteria for this procedure and a brief literature review.

An outcome analysis of laparoscopic management of diverticulitis

BackgroundAll operative procedures for simple or complicated diverticulitis, including primary resection and anastomosis (PRA) with or without a diverting stoma, Hartmann procedure (HP), or stoma reversal, whether done in an elective setting or as an emergency, can be performed laparoscopically. However, owing to low incidence of the disease and complexity of the procedure, there are very few studies on outcomes of laparoscopic surgery for sigmoid diverticulitis from India.AimThe present study was undertaken to evaluate outcomes of laparoscopically treated patients of sigmoid diverticulitis.MethodsProspective observational study enrolled 37 patients with sigmoid diverticulitis managed laparoscopically from March 2015 to March 2017. Demographic, clinical, operative, postoperative, and complication data were entered into a patient proforma and analyzed.ResultsEleven simple and 26 complicated diverticulitis patients were operated laparoscopically, 22 in emergency setting and 15 in elective setting. Only three patients required conversion to open surgery—two due to dense adhesions and one due to chronic obstructive pulmonary disease (COPD). No patients had ureteric or bowel injury. Eighteen patients underwent laparoscopic PRA without stoma, 11 patients had PRA with stoma, 6 had HP, and 2 had laparoscopic lavage. Results showed lesser blood loss, shorter hospital stay, and fewer complications in the elective group and simple diverticulitis patients. None of the patients had anastomosis-related complications. Two patients had stoma-related complications.ConclusionLaparoscopic management of diverticulitis is feasible, safe, provides the benefits of less wound-related complications, and shorter hospital stay and should be the surgical procedure of choice in elective or emergency setting for simple/complicated diverticulitis.

BRUNNER GLAND ADENOMA MASQUERADING AS DUODENAL GASTROINTESTINAL STROMAL TUMOR WITH INTUSSUSCEPTION: CASE REPORT

Brunner gland adenoma (Brunerroma or hamartoma) is a rare, benign lesion of the Brunner’s glands, accounting for 10.6% of benign duodenal tumors10. It is predominantly seen in the 5th to 6th decades and with no gender predilection13. It is often an incidental finding during esophagogastroduodenoscopy or imaging studies. In symptomatic patients, clinical manifestations include gastrointestinal bleeding, duodenal obstruction, abdominal pain, ampullary obstruction, or intussusception8,9. Given their potential to be mistaken as cancer, it is important to consider it in the differential diagnosis of duodenal masses14. As there have been reports of focal cellular atypia and adenocarcinoma within the lesion, resection, whether endoscopic or surgical is recommended for suspected Brunneromas3. We report here a case of Brunneroma, which presented as gastrointestinal stromal tumor (GIST) with intussusception on radiological and endoscopic studies and brief review of literature.

Cystic Dystrophy of the Duodenum Due to Heterotopic Pancreas – A Case Report and Review of Literature

Cystic Dystrophy and Heterotopic Pancreas (CDHP) is a rare cause of chronic pancreatitis, duodenal obstruction and obstructive jaundice. The diagnosis is often delayed and requires multimodal imaging with Computed Tomography (CT), Magnetic Resonance Cholangio-Pancreatography (MRCP) and Endoscopic Ultrasound (EUS). The treatment is not standardized but Pancreatoduodenectomy (PD) provides long-term relief in some cases. The present case is about a 47-year-old male with history of alcohol abuse for 10 years who presented with a history of recurrent acute pancreatitis. CT scan revealed bulky head of pancreas with a hypodense area between pancreatic head and second part of duodenum, prominent pancreatic duct, Dilated Common Bile Duct (CBD) (15mm) and stenosis of second part of duodenum. EUS confirmed CT findings. A Fine Needle Aspiration Cytology (FNAC) showed only inflammatory infiltrate. A diagnosis of groove pancreatitis was made. The patient was subjected to a pylorus preserving PD. Histopathological examination showed cystic dystrophy of duodenum due to heterotopic pancreas. The patient is doing well at 5 years of follow-up.

De novo pelvic abscess: An unreported primary presentation of Pott's spine

Potts spine leading to pelvic abscess is an uncommon presentation of tuberculosis. We recently cared for a young male who presented with a pelvic abscess without evidence of any primary genitourinary or bowel pathology. On computed tomography (CT), patient was found to have Potts spine as the primary pathology. The pelvic abscess was drained by high transrectal drainage and its tubercular nature was confirmed by microbiological tests. Patient was subsequently stated on antitubercular drugs. Our patient is a rare and the first reported case of a young immunocompetent male who presented with a pelvic abscess as the sole manifestation of Potts spine without coexisting psoas involvement or any neurological deficit. To conclude, any patient presenting with pelvic abscess, Potts spine should be considered amongst the differential diagnosis especially in endemic regions.