Mukta Ramadwar

Solid pseudopapillary neoplasm of the pancreas: a single institution experience of 14 cases.

Solid pseudopapillary neoplasm of pancreas (SPN) is a rare entity; therefore proper diagnosis, evaluation and formulation of treatment protocols is difficult. A total of 14 cases were diagnosed and treated at our institute over a 10-year period (1992-2002). A retrospective study of all these cases was performed with respect to age group most frequently affected, sex ratio, common presenting symptoms and signs, investigative protocols, pathological features, treatment offered, outcome and prognosis. All the 14 patients were females, with a median age of 20 years (range 13-45 years). The commonest presenting symptom was abdominal pain. All these patients underwent surgical exploration; 13 patients underwent resection of the tumour. The average length of postoperative hospital stay was 10.3 days. Significant postoperative morbidity was seen in only one case. There was no postoperative mortality. All these patients who underwent resection were disease-free on follow-up ranging from 6 to 96 months (median 36 months).

NASOPHARYNGEAL CARCINOMA IN CHILDREN: COMPARISON OF CONVENTIONAL AND INTENSITY-MODULATED RADIOTHERAPY

PURPOSE To evaluate the efficacy of intensity-modulated radiotherapy (IMRT) in reducing the acute toxicities associated with conventional RT (CRT) in children with nasopharyngeal carcinoma. PATIENTS AND METHODS A total of 36 children with nonmetastatic nasopharyngeal carcinoma, treated at the Tata Memorial Hospital between June 2003 and December 2006, were included in this study. Of the 36 patients, 28 were boys and 8 were girls, with a median age of 14 years; 4 (11%) had Stage II and 10 (28%) Stage III disease at presentation. All patients had undifferentiated carcinoma and were treated with a combination of chemotherapy and RT. Of the 36 patients, 19 underwent IMRT and 17 underwent CRT. RESULTS After a median follow-up of 27 months, the 2-year locoregional control, disease-free, and overall survival rate was 76.5%, 60.6%, and 71.3%, respectively. A significant reduction in acute Grade 3 toxicities of the skin (p = 0.006), mucous membrane (p = 0.033), and pharynx (p = 0.035) was noted with the use of IMRT. The median time to the development of Grade 2 toxicity was delayed with IMRT (skin, 35 vs. 25 days, p = 0.016; mucous-membrane, 39 vs. 27 days, p = 0.002; and larynx, 50 vs. 28 days, p = 0.009). The duration of RT significantly influenced disease-free survival on multivariate analysis (RT duration >52 days, hazard ratio = 5.49, 95% confidence interval, 1.14-26.45, p = 0.034). The average mean dose to the first and second planning target volume was 71.8 Gy and 62.5 Gy with IMRT compared with 66.3 Gy (p = 0.001) and 64.4 Gy (p = 0.046) with CRT, respectively. CONCLUSION The results of our study have shown that IMRT significantly reduces and delays the onset of acute toxicity, resulting in improved tolerance and treatment compliance for children with nasopharyngeal carcinoma. Also, IMRT provided superior target coverage and normal tissue sparing compared with CRT.

An analysis of 46 static telecytology cases over a period of two years

We analysed 46 telecytology cases sent from two rural hospitals about 500 km from a tertiary cancer centre. The cases were submitted for second opinion over a period of two years and evaluated using a static store and forward telecytology approach. A total of 715 digital images were studied (average 15 per case). Forty-one of the 46 cases (89%) were reported within 3 days and 54% of cases were reported within one working day. The aspiration smears and images were found to be of diagnosable quality in 89 and 93% of the cases, respectively. The diagnostic concordance was assessed by comparing the telecytology diagnosis, glass slide diagnosis and final histopathology diagnosis (when available). A clinically useful diagnosis was rendered in 91% cases with 74% complete concordance. Five out of 46 cases (11%) were deferred for glass slide review. Store and forward telecytology using the Internet is a rapid and effective method of providing expert diagnosis in cytology.

Orbital medulloepitheliomas—With extensive local invasion and metastasis: A series of three cases with review of literature

Intraocular medulloepithelioma is a rare embryonal neoplasm which usually presents in childhood as a ciliary body mass. This tumor is usually confined to the orbit and rarely tends to be locally aggressive and metastatic. We describe three rare cases of metastatic malignant teratoid medulloepithelioma. The patients were males aged 7, 16 and 25 years with right eye involvement in all the cases. All patients had local recurrence (multiple in two) and metastasis to the intraparotid and cervical lymph nodes. Distinction from round cell tumors and primary salivary gland neoplasms occurring in the parotid gland is strongly warranted, especially in biopsy samples, because the biological behaviour and treatment of medulloepithelioma differs greatly from the above lesions.

A rare case of primary gastric plasmacytoma: An unforeseen surprise

Primary plasmacytoma of the gastrointestinal tract is a rare entity. We report a case of a primary gastric plasmacytoma in a 57-year-old man who presented with upper-gastrointestinal bleeding. Endoscopy showed a nodular gastric mass with central umblication. Histological examination of the gastrectomy specimen revealed a monoclonal lambda-chain extramedullary plasmacytoma. Further staging was found to be negative for multiple myeloma. As other more common pathologic processes at this site may also be endowed with numerous plasma cells, awareness of this entity and distinction using immunohistochemistry are extremely crucial. Because systemic disease ultimately develops in many patients with localized plasmacytoma, such patients should be followed closely for the appearance of clinical, biochemical, and roentgenologic evidence of multiple myeloma.

D2 Lymphadenectomy for Gastric Cancer in Tata Memorial Hospital: Indian Data Can Now Be Incorporated in Future International Trials

Background: While mortality rates after radical gastrectomy have decreased, there is considerable morbidity after D2 lymphadenectomy. In this study, we assessed the perioperative results of D2 gastrectomy for gastric cancer. Materials: Data of 159 patients who underwent D2 gastrectomy for gastric adenocarcinoma at Tata Memorial Hospital was analyzed for interim analysis. The extent of resection, blood loss, transfusions, duration of hospitalization, number of lymph nodes dissected, complications, morbidity and mortality were analyzed. Results: 130 and 29 patients underwent distal and total gastrectomy, respectively (2002–2005) by single specialized surgical unit. Median age was 55 years (range 21–78) and blood loss was 450 ml (range 100–2,200 ml). The median duration of hospitalization was 13 days (range 7–52 days). The median number of dissected lymph nodes was 15 (range 2–46). Minor and major morbidity rate was 4.4 and 4.4% respectively. Mortality rate was 1.25%. Conclusion: Morbidity and mortality following D2 lymphadenectomy is low in this first prospective study from India. With Japan and Western countries having polarized views on D2 lymphadenectomy, future international multicenter trials could also incorporate data such as ours from areas of high incidence of gastric cancer since perioperative outcomes would no longer cloud their results and might provide a better global perspective on D2 lymphadenectomy.

Spinal epidermoid cyst with sudden onset of paraplegia

Spinal epidermoid cysts, whether congenital or iatrogenic, are relatively uncommon in the spinal cord. When they occur, the typical location is in the subdural, extramedullary space of the lumbo-sacral region. We describe an unusual presentation in a 3-year-old male child which mimicked astrocytoma clinicoradiologically. The child developed sudden onset of inability in walking and weakness of both lower limbs after a fall. There was a dramatic reversal of symptoms after surgery. Histopathology revealed an epidermoid cyst of the spine. On the first follow-up visit at 3 months, the child was asymptomatic.

Desmoplastic Small Round Cell Tumor-Clinicopathological Spectrum, Including Unusual Features and Immunohistochemical Analysis of 45 Tumors Diagnosed at a Tertiary Cancer Referral Centre, with Molecular Results t(11; 22) (p13; q12) (EWS-WT1) in Select Cases

Desmoplastic small round cell tumor (DSRCT) is a distinct soft tissue tumor of uncertain histogenesis, mostly composed of small round cells; is characterized by polyphenotypic differentiation and a translocation t(11; 22)(p13; q13), resulting in formation of a specificEWS-WT1 fusion gene transcript [1]. This tumor was initially described by Sesterhenn et al. [2] as an undifferentiated malignant epithelial tumor involving serosal surfaces of scrotum and abdomen in young males. In 1989, Gerald and Rosai [3] published the first case that they designated as a desmoplastic small round cell tumor (DSRCT) with divergent differentiation. In the following year, Gonzalez-Crussi et al. [4] documented three additional cases of an intra-abdominal DSRCT. Subsequently, Gerald et al. [5] published the first large series of IADSRCT stating its predilection for adolescent males; an almost intra-abdominal location with rare secondary organ involvement and its classical histopathological features. Sawyer et al. [6] identified t (11; 22) (p13; q13) translocation for the first time in an IADSRCT. Ordonez et al. [7] identified a single case of ‘IADSRCT’ in the scrotum in their series of 22 cases. Thereafter, this tumor has been documented in form of series and case reports in intra and extra-abdominal sites like ovary, paratesticular region, pleura, soft tissues, including head and neck and finally recognized as a DSRCT [1, 8–16]. It is a highly malignant tumor that displays variable epithelial, mesenchymal and neural differentiation, demonstrated by immunohistochemical stains; mostly involves abdominal sites of young male patients, spreads along serosal surfaces; has an aggressive clinical course with frequent recurrences, rarely metastasis and is refractory to conventional, individual treatment modalities like surgery, chemotherapy (CT) and radiotherapy (RT). Apart from its classical histopathological features, including small round cells embedded in a desmoplastic stroma, a spectrum of features has been described, including tumors B. Rekhi (*) : S. Ahmed : S. S. Desai :M. Ramadwar : S. B. Desai :N. A. Jambhekar Department of Pathology, Tata Memorial Hospital, Dr E.B. Road, Parel, Mumbai, India 400012 e-mail: rekhi.bharat@gmail.com

Are we achieving the benchmark of retrieving 12 lymph nodes in colorectal carcinoma specimens? Experience from a tertiary referral center in India and review of literature.

INTRODUCTION The number of lymph nodes (LNs) retrieved from a specimen of colorectal carcinoma may vary. Factors that can possibly affect LN yield are age of the patient, obesity, location of the tumor, neoadjuvant therapy, surgical technique and pathologists handling of the specimen. AIM The aim of our study is to look at lymph node retrieval from colorectal cancer (CRC) specimens in our hands and review the literature. MATERIALS AND METHODS From May 2010 to January 2011, a total of 170 colorectal carcinoma cases were operated in our institute. Type of the surgeries, lymph node yield was looked at. RESULTS There were 103 (60.6%) males and 67 (39.4%) females. The commonest age group was 50-59 years (30.6%). The surgeries included 107 surgeries for rectal carcinoma (63%) and 63 surgeries for colonic carcinoma (37%). Sixty six (38.8%) cases had received preoperative chemoradiotherapy, whereas 104 (61.2%) cases were without adjuvant therapy. The total lymph node positivity (metastatic disease) was 44.7% .The overall mean lymph node yield was 12.68 (range 0-63; median 11). The mean lymph node harvest in the age group < 39 was 15.76 whereas, the lymph node harvest in the group more than 39 years old was 11.90. ( statistically significant; P=0.03). The mean lymph node yield from specimens of rectal cancers (10.30) was lower than the mean lymph node yield from specimens for colonic cancers (16.71);( statistically significant, P<0.01). There was also statistically significant difference between the mean LN yield in chemoradionaiive cases (14.63) and in the cases where neoadjuvant therapy was received, (9.59); P<0.01. CONCLUSION Pathologist while assessing a specimen of CRC should aim to retrieve a minimum of 12 LN. Surgical expertise and diligence of the pathologists remain two main alterable factors that can improve this yield. Neoadjuvant or preoperative radiotherapy can yield in less number of nodes.

Simultaneous gallbladder and bile duct cancers: revisiting the pathological possibilities

The pathogenesis of gallbladder cancer presenting synchronously with malignancy of the bile duct has not been clearly understood. The possible causes for the simultaneous presence of these tumors could be due to local spread, metastases, de novo multifocal origin, or as part of a field change in the extrahepatic biliary apparatus. In this article, we discuss the cases of four patients with simultaneous gallbladder and bile duct malignancies and analyze their individual pathologies to provide an explanation into the mechanisms that may play a role in such conditions.