Seema Mehrotra

Implications of free radicals and antioxidant levels in carcinoma of the breast: A never-ending battle for survival

BACKGROUND Under normal circumstances, there is a steady balance between the production of oxygen derived free radicals and their destruction by the cellular antioxidant system inside the human body. However, any imbalance between the levels of these oxidants and antioxidants might cause DNA damage and may lead to cancer development. The aim of this study was to evaluate the level of antioxidants and free radicals in blood and tissue of cancer patients and compare these levels at different TNM stages to derive the possible role of free radicals and antioxidant enzymes in the etiology of breast cancer. MATERIALS AND METHODS This study includes 30 patients suffering from cancer breast and 20 patients as controls who had benign breast diseases. Circulating lipid peroxide (Malonyldialdehyde [MDA]) levels and activities of the defensive enzymes (Superoxide Dismutase [SOD] and Catalase [CAT]) were estimated in the blood and breast tissue of these patients. RESULTS Increased levels of free radicals and low levels of antioxidants were observed in malignant tissue. An elevated lipid peroxide concentration was found in the tissue of all the cancer breast patients as evidenced by an increase in the mean MDA level seen with increasing TNM stage of carcinoma breast. Levels of antioxidants SOD and CAT were decreased in cancer patients. CONCLUSION The results of our study suggest that free radical activity is enhanced in cancer breast patients while the antioxidant defense mechanism is weakened. This activity is enhanced with the increasing severity of cancer as depicted in different TNM stages of breast cancer.

Squamous Cell Carcinoma of the Kidney â Rarity Redefined: Case Series with Review of Literature

Squamous cell carcinoma of the renal pelvis and ureter is a rare malignancy, having an incidence of 6% to 15% (of all urothelial tumors). Few cases of primary squamous cell carcinoma of kidney have been reported in the world literature. The insidious onset of symptom and lack of any pathognomonic sign, leads to delay in the diagnosis and subsequent treatment, resulting in grave prognosis for these patients. Herein, we report 5 cases (three males and two females) of advanced primary squamous cell carcinoma of kidney that were treated at our centre during the last 6 years. The average age was 57 years (range 50-65 years). Three of the patients had history of long standing renal calculus disease while 3 had history of smoking and 1 patient had history of analgesic abuse. These cases were unique because in few of them; all the calyces were involved by the tumor - a field change type of pattern normally seen in transitional cell carcinoma of the kidney. In one patient, thrombus of the inferior vena cava was also present along with infi ltration of the duodenum by the tumor. Despite prompt nephroureterectomy, 4 out of 5 patients died within 6 months of treatment. Only one patient was surviving at 5 months of follow up. Nephrectomy with or without ureterectomy is the treatment of choice in patients suffering from squamous cell carcinoma of the kidney. There is lack of evidence of survival benefi ts of chemo-radiation following surgery but is advocated by some with the hope that it might increase survival. Biopsy from the renal pelvis or calyceal wall is advocated at the time of stone removal in patients having long-standing history of large renal calculi or staghorn calculus since such patients are capable of harboring occult or overt malignancy.

Transperitoneal Transvesical Laparoscopic Repair of Vesicovaginal Fistulae: Experience of a Tertiary Care Centre in Northern India

Objective: To present our experience of treating supratrigonal vesicovaginal fistulae by laparoscopic technique and their long-term follow-up. Material and Methods: Between January 2008 and June 2012, 28 cases of supratrigonal fistulas were repaired by laparoscopic transperitoneal transvesical technique with interposition flap. The obstetric fistula was present in 18 and gynecologic fistula in 10 patients. Single supratrigonal fistula was present in 26 patients and in 2 patients there were 2 fistulae lying side to side. The vaginal opening was closed as single layer interrupted suture and cystotomy closed as single layer continuous suture by 3-0 polygalactin. The omentum was used as interposition flap in all except 2 cases in whom postero-superior vesical fold of peritoneum was used. The open conversion was required in 2 cases. The urethral catheter was removed in 4 weeks following a micturating cystogram. Result: The mean fistula size was 1.2 cm (range 0.8-2.5 cm). Open conversion was performed in 2 cases of whom one had excess carbon-dioxide retention and cardiac arrhythmia and in another case the needle of 3-0 polygalactin was avulsed and lost in peritoneal cavity which was recovered following laparotomy. All patients were continent following the catheter removal. The median follow-up is 24 months. None developed any complication related to laparoscopic repair till last follow-up. Conclusion: Laparoscopic repair of supratrigonal vesicovaginal fistulae is an effective and safe minimally invasive treatment with excellent result.

Cutaneous metastasis from cervical carcinoma: An ominous prognostic sign

congenital adrenal hyperplasia. These tumours may produce oestradiol, leading to menorrhagia or postmenopausal bleeding. Cushing’s syndrome due to elevated serum prorenin has also been reported (Hayes et al. 1987). Magnetic resonance imaging is immensely useful in the characterisation of adnexal masses. Steroid cell tumours typically show an intermediate signal intensity solid mass with homogenous intense enhancement. Less commonly, they can be patchy with cystic and solid areas (Jung et al. 2005). If no tumour is identified, despite imaging studies, percutaneous sampling of the ovarian and adrenal vessels may be successful in identifying small steroid secreting tumours (De Freitas et al. 1991). Radiolabelled steroid scans using aldosterol, iodocholesterol and Se75 can identify ovarian steroid secreting tumours (De Freitas et al. 1991). The clinical behaviour of these tumours is uncertain. Treatment in older women consists of total abdominal hysterectomy and bilateral salpingo-oophorectomy with proper surgical staging. In younger women with stage 1 disease who wish to preserve their fertility, unilateral oophorectomy should be done (Reedy et al. 1999). The most accurate predictor of malignant behaviour is the presence of two or more mitotic figures per high power field. Malignant tumours also display grade 2–3 nuclear atypia, haemorrhage, necrosis and a diameter of 47 cm (Hayes and Scully 1987). In a large study, the Gynecologic Oncology Group assessed the efficacy of Bleomycin, etoposide and platinum and found this regimen to be immensely effective in women with primary and recurrent disease (Homesely et al. 1998). Gonadotropin-releasing hormone agonists have been used in the past as primary treatment to achieve complete resolution of ovarian androgen secreting tumour (Bames and Ehrmann 1997). Post-treatment follow-up using serum testosterone levels is recommended in view of the unpredictable behaviour of these tumours. Steroid cell tumours NOS are among the rarest of the ovarian tumours. They can be difficult to diagnose as the ovary may appear completely normal. Magnetic resonance imaging is valuable in arriving at a diagnosis.

A prospective double blind trial investigating impact of vaginal pH on efficacy of prostaglandin gel for cervical ripening and course of labour

This prospective, double blind investigation was carried out to see the effect of vaginal pH on the efficacy of prostaglandin gel (PGE2) for cervical ripening and course of labour. A total of 45 pregnant women with indications for induction of labour were allocated to two groups: a low vaginal pH (≤5.5, n = 20) and high vaginal pH (>5.5, n = 25) group. All women received prostaglandin E2 gel (0.5 mg in 2.5 ml) intravaginally with repeated dosing if needed, 6 h apart, maximum of three doses. Bishops score change over 18 h differed significantly between the two groups (p = 0.037). There was no significant difference between the groups with respect to time to onset of labour (9.65±6.29 vs 6.76±3.94, p = 0.066), time to active labour (15.38±9.49 vs 14.30±5.85, p = 0.664), time to complete cervical dilation (18.27±13.85 vs 18.34±6.45; p = 0.984), and time to overall delivery (21.52±9.66 vs 19.39±6.45, p = 0.381).

A prospective double blind study using oral versus vaginal misoprostol for labour induction

This prospective double blind study was undertaken to compare the safety and efficacy of oral vs vaginal misoprostol in equivalent doses (50 μg) for induction of labour. A total of 128 term pregnancies with indication for induction of labour were allocated to two groups to receive 50 μg misoprostol orally or vaginally, every 4 h until adequate contractions were achieved or a maximum of 200 μg dose. Induction to delivery interval was significantly shorter in the vaginal group compared with the oral group (14.6 h vs 22.5 h; p < 0.001). There was no significant difference between the groups with respect to mode of delivery, neonatal outcome and maternal side-effects. However, the incidence of abnormal contractility pattern was more common in the vaginal group (10/68, 14.6%) as compared with the oral group (4/60, 6.6%) (p = 0.146).

Cystohysteroscopy: novel use of semi-rigid ureteroscope to establish an access via fistulous tract between urinary bladder and vagina for confirming the diagnosis and facilitating laparoscopic repair of vesicouterine fistula.

In patients with vesicouterine fistula (VUF), identification of the fistulous tract during laparoscopic surgery remains difficult. Hysterography and intravesical instillation of dye have been the traditional methods for diagnosing VUF; now, they have been supplanted by ultrasonography, CT, and/or MRI. Unfortunately, none of the above mentioned investigations aid in identification of the fistulous tract during laparoscopic surgery or ease laparoscopic dissection. We describe a simple procedure, which we term cystohysteroscopy, that aids the diagnosis of VUF and also simplifies laparoscopic dissection. A guidewire/ureteral catheter is coiled in the uterine cavity through the fistulous tract with the help of a cystoscope. By cystohysteroscopy, this guidewire/ureteral catheter is pulled out through the vagina using a semirigid ureteroscope. The advantage of cystohysteroscopy is that the presence of the guidewire/ureteral catheter across the fistulous tract aids laparoscopic dissection even in the presence of fibrosis and can be used for traction/manipulation during dissection in the vesicouterine area. This is the first report in the literature depicting the use of a semirigid ureteroscope for the purpose of cystohysteroscopy.

Long-term outcome of laparoscopic vesicouterine fistula repair: Experience from a tertiary referral centre

Objective Vesicouterine fistula (VUF) is an uncommon cause of female genito-urinary fistula. Most of these fistulas are due to lower segment uterine cesarean section (LSCS). Traditionally, open surgical repair has been the traditional treatment. However, laparoscopic repair of VUF is a minimally invasive technique and few case reports have been published with short term follow up. In the present study, we are presenting our long- term outcome of laparoscopic repair of VUF. Material and methods A retrospective analysis of 8 patients with VUF was performed from 2010 to 2015. Approval of Institutional Review Committee was obtained. All had history of LSCS of whom 3 had history of prolonged obstructed labor. Radiological imaging included ultrasound of kidney, ureter and bladder for all patients and hysterosalphingography in 4 patients and contrast enhanced computed tomography scan in 4 patients. Results Median age of the patient was 25.5 years (range, 22-32), and median follow up was 2.3 years (range, 1 -4). The most common presentation was cyclical menstrual bleeding through urine (menouria) in all, associated amenorrhea in 6 and vaginal leakage of urine in 2 cases. All patients underwent laparoscopic repair with successful outcomes. The mean operating time was 155±14.5 min (range, 135-186 min) with a median blood loss of 100 mL (range, 50-210 mL). Successful pregnancy was completed in 2 patients and other patients were taking contraceptives. Conclusion Laparoscopic repair of VUF is a safe and effective minimally invasive technique with successful pregnancy in long- term follow up.

Molar pregnancy in postmenopausal women: a rare phenomenon

Benign gestational trophoblastic disease generally occurs in women of the reproductive age group and is extremely rare in postmenopausal women. We describe a case of complete hydatidform mole in a 60-year-old postmenopausal woman who was referred with diagnosis of suspected malignancy/myoma resulting in delay in management. This case highlights the fact that gestational trophoblastic disease can occur in menopausal woman and this should be included in the differential diagnosis of perimenopausal and postmenopausal haemorrhage to prevent delay in diagnosis and treatment.

Massive rectus sheath haematoma mimicking abruptio placenta

expensive and exposes patient to ionising radiation (Moreno et al. 1997). Conservative management of RSH with rest, analgesics and discontinuation of anticoagulant therapy, blood and blood products transfusion as and when necessary, is feasible in the majority of the patients. Caesarean section could have been avoided if the correct diagnosis had been promptly made. Although conservative management is desirable, it is vital for all obstetricians to have a low threshold for surgical intervention in a haemodynamically unstable patient or if haematoma is complicated by anticoagulant therapy. This case also highlights the importance of being familiar with the clinical presentation of RSH in pregnancy. The sonographer should be prepared to make a firm diagnosis as this goes a long way in reducing unnecessary surgical intervention and decrease maternal and perinatal morbidity and mortality associated with RSH in pregnancy.