Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Actinobacillus ureae: an unusual cause of tree-in-bud pattern in a case of pneumonia on lung computed tomographic scan-first clinical case report and review of the literature from India

A 62-year-old man with asthma sought care for intermittent fever, cough with expectoration, breathlessness and orthopnoea with grunting. Computed tomography revealed clusters of centrilobular nodules on both sides with a tree-in-bud appearance and mild diffuse bronchial wall thickening. Sputum sample grew pure colonies of Actinobacillus ureae which was confirmed by MALDI-TOF and 16SrRNA gene sequencing. A. ureae may be an additional bacteriologic causative agent of the tree-in-bud pattern on computed tomographic scan.

Escherichia vulneris: an unusual cause of complicated diarrhoea and sepsis in an infant. A case report and review of literature

Escherichia vulneris is an opportunistic human pathogen. It has been primarily reported in adult patients and invasive infections have been observed in immune-suppressed individuals. This is the first report of E. vulneris causing complicated diarrhoea and sepsis in an infant.

Two month old sick infant, born full-term, was admitted to the paediatrics department with loose motions and refusal to feed for four days. E. vulneris was isolated from blood in pure culture. The isolate was characterized for diarrhoeal virulence markers: heat labile and heat stable toxins (LT, ST) and hemolysin (hlyA) by PCR. The presence of LT enterotoxin and hemolysin provides strong evidence of the diarrhoeagenic potential of E. vulneris, further leading to the invasive infection triggering sepsis.

As E. vulneris can lead to serious complications, an attempt should be made in clinical laboratories to identify and further characterize this new Escherichia species.

Linezolid-resistant mucoid Staphylococcus haemolyticus from a tertiary-care centre in Delhi

We report an unusual morphological mucoid variant of Staphylococcus haemolyticus associated with linezolid resistance from a patient with sepsis. Linezolid resistance and mucoid character together made this pathogen difficult to treat. To our knowledge this is the first such report.

Corynebacterium striatum: an emerging nosocomial pathogen in a case of laryngeal carcinoma

Corynebacterium striatum is an emerging nosocomial pathogen associated with wound infections, pneumonia and meningitis. It is also a multidrug-resistant pathogen causing high morbidity. This is a report of an unusual case of wound infection in a patient with laryngeal carcinoma. Accurate diagnosis of the infection and prompt management helped in a favourable outcome for the patient. This case highlights the role of C. striatum as an important nosocomial pathogen in immunocompromised patients.

Myelofibrosis in children: experience at a single tertiary care center in India

The authors describe 10 cases of myelofibrosis diagnosed and managed at their center over 16 years. There were 2 and 8 cases, respectively, of primary and secondary myelofibrosis. All patients presented with fever, pallor, hepatosplenomegaly, and/or lymphadenopathy. Hodgkin's lymphoma (n = 4), neuroblastoma (n = 1), thrombasthenic thrombopathy (n = 1), and retroperitoneal-mass (n = 1) were causal in 7 patients, whereas the diagnosis could not be established in a sole case of secondary myelofibrosis. Patients were managed with chemotherapy and appropriate care. However, outcome was poor. The authors emphasize variable clinical-laboratory spectrum of myelofibrosis, highlight management concerns, and demonstrate that prognosis/outcome depends upon appropriate management of the underlying condition.

A case-control study of tobacco smoking and tuberculosis in India

OBJECTIVES

To evaluate the role of smoking as a risk factor for the development of pulmonary tuberculosis.

MATERIALS AND METHODS

A total of 111 sputum smear-positive patients of pulmonary tuberculosis and 333 controls matched for age and sex were interviewed according to a predesigned questionnaire.

RESULTS

The adjusted odd ratio of the association between tobacco smoking and pulmonary tuberculosis was 3.8 (95% confidence interval, 2.0 to 7.0; P value, < 0001). A positive relationship between pack years, body mass index and socioeconomic class was also observed.

CONCLUSION

There is a positive association between tobacco smoking and pulmonary tuberculosis.

Diffuse large B-cell lymphoma: experience from a tertiary care center in North India

Limited information is available from developing countries regarding clinico-pathological presentation of diffuse large B-cell lymphoma (DLBCL). We undertook a retrospective case record study to determine the clinico-laboratory characteristics, treatment outcomes, and prognostic factors for DLBCL and additionally analyzed percentage distribution and patient characteristics for other major subtypes of non-Hodgkin's lymphoma (NHL). DLBCL, constituting 59.3% of all NHL cases, was the predominant subtype. For DLBCL, males:females ratio was 2.7:1 and the median age at presentation was 47 years. Lymphadenopathy was present in 57% patients and B symptoms in 56.7%. A total of 49.3% of patients had Ann Arbor Stage IV disease. Significant differences were observed between favorable (international prognostic index [IPI]-0, 1, and 2) and unfavorable prognosis groups (IPI-3, 4, and 5) with regards to mean hemoglobin levels (P < 0.005), platelet counts (P < 0.05), serum albumin levels (P < 0.05), and erythrocyte sedimentation rates (P < 0.005), thereby suggesting their role as prognostic markers in our population. The median event free survival was 32 months (95% CI: 0-92 months) and the median overall survival was 47 months (95% CI: 3-100 months). Among total NHL, the earlier age of onset, male dominant sex ratio, and higher frequency of B symptoms sets apart NHL in Indian population from that in the developed countries.

Improving care in ovarian cancer: the role of a clinico-pathological meeting

BACKGROUND

We assessed the impact of clinico-pathological meetings on the diagnosis and management of patients with ovarian cancer.

METHODS

Between January 2005 and December 2006, about 400 patients of suspected or confirmed ovarian cancer were evaluated in the 'Gynaecology Tumour Clinic'. Of these, 108 cases were referred for discussion in the weekly clinico-pathology meeting for various indications. These cases were retrospectively analysed regarding their initial clinical and pathological diagnosis, the indication for referring the case for discussion in the meeting and the impact this had on the overall management. Alterations in diagnosis, which impacted management, were classified as 'major changes' and those, which did not, were called 'minor changes'.

RESULTS

Ninety-one of the 108 cases discussed were available for analysis; 75.8% of cases were initially diagnosed as epithelial ovarian cancers. In 48 of 91 cases (52%), there was an alteration in the diagnosis as a direct result of discussion in the meeting, mainly after clarifications regarding histological grading in 34 cases. Of the remaining 14 cases, 3 had a change in histopathological diagnosis; 2 cases, which were initially labelled as undifferentiated tumours, had their diagnosis clarified; and in the remaining 9 cases, in which the primary site was not known, a possible primary site could be assigned (with the help of clinical, radiological and pathological inputs). Among the 14 cases with alterations other than grading, the change was contributed by slide review alone in 7 cases and in the rest by a combination of slide review and clinical inputs. As a direct outcome of the meeting, 20 of 91 cases (22%) had their management plan modified (major change).

CONCLUSION

The practice of conducting weekly clinicopathological meetings has a major impact on the management of cases of ovarian cancer.

A phase II study of sequential neoadjuvant gemcitabine plus doxorubicin followed by gemcitabine plus cisplatin in patients with operable breast cancer: prediction of response using molecular profiling

This study examined the pathological complete response (pCR) rate and safety of sequential gemcitabine-based combinations in breast cancer. We also examined gene expression profiles from tumour biopsies to identify biomarkers predictive of response. Indian women with large or locally advanced breast cancer received 4 cycles of gemcitabine 1200 mg m(-2) plus doxorubicin 60 mg m(-2) (Gem+Dox), then 4 cycles of gemcitabine 1000 mg m(-2) plus cisplatin 70 mg m(-2) (Gem+Cis), and surgery. Three alternate dosing sequences were used during cycle 1 to examine dynamic changes in molecular profiles. Of 65 women treated, 13 (24.5% of 53 patients with surgery) had a pCR and 22 (33.8%) had a complete clinical response. Patients administered Gem d1, 8 and Dox d2 in cycle 1 (20 of 65) reported more toxicities, with G3/4 neutropenic infection/febrile neutropenia (7 of 20) as the most common cycle-1 event. Four drug-related deaths occurred. In 46 of 65 patients, 10-fold cross validated supervised analyses identified gene expression patterns that predicted with >or=73% accuracy (1) clinical complete response after eight cycles, (2) overall clinical complete response, and (3) pCR. This regimen shows strong activity. Patients receiving Gem d1, 8 and Dox d2 experienced unacceptable toxicity, whereas patients on other sequences had manageable safety profiles. Gene expression patterns may predict benefit from gemcitabine-containing neoadjuvant therapy.

Molecular characterization of ciprofloxacin-resistant Salmonella enterica serovar Typhi and Paratyphi A causing enteric fever in India

OBJECTIVES

To define the genetic characteristics and resistance mechanisms of clinical isolates of Salmonella enterica serovar Typhi (S. Typhi) and S. enterica serovar Paratyphi A (S. Paratyphi A) exhibiting high-level fluoroquinolones resistance.

METHODS

Three S. Typhi and two S. Paratyphi A ciprofloxacin-resistant isolates (MICs > 4 mg/L) were compared with isolates with reduced susceptibility to ciprofloxacin (MICs 0.125-1 mg/L) by PFGE, plasmid analysis, presence of integrons and nucleotide changes in topoisomerase genes.

RESULTS

In S. Typhi and Paratyphi A, a single gyrA mutation (Ser-83-->Phe or Ser-83-->Tyr) was associated with reduced susceptibility to ciprofloxacin (MICs 0.125-1 mg/L); an additional mutation in parC (Ser-80-->Ile, Ser-80-->Arg, Asp-69-->Glu or Gly-78-->Asp) was accompanied by an increase in ciprofloxacin MIC (> or = 0.5 mg/L). Three mutations conferred ciprofloxacin resistance: two in gyrA (Ser-83-->Phe and Asp-87-->Asn or Asp-87-->Gly) and one in parC. This is the first report of parC mutations in S. Typhi. Ciprofloxacin-resistant S. Typhi and S. Paratyphi A differed in their MICs and mutations in gyrA and parC. Moreover S. Typhi harboured a 50 kb transferable plasmid carrying a class 1 integron (dfrA15/aadA1) that confers resistance to co-trimoxazole and tetracycline but not to ciprofloxacin. PFGE revealed undistinguishable XbaI fragment patterns in ciprofloxacin-resistant S. Typhi as well as in S. Paratyphi A isolates and showed that ciprofloxacin-resistant S. Typhi have emerged from a clonally related isolate with reduced susceptibility to ciprofloxacin after sequential acquisition of a second mutation in gyrA.

CONCLUSIONS

To our knowledge this is the first report of molecular characterization of S. Typhi with full resistance to ciprofloxacin. Notably, the presence of a plasmid-borne integron in ciprofloxacin-resistant S. Typhi may lead to a situation of untreatable enteric fever.

Primary gastrointestinal non Hodgkin's lymphoma chemotherapy alone an effective treatment modality: experience from a single centre in India

BACKGROUND

Gastrointestinal tract (GI) is the most frequently involved extra nodal site in non-Hodgkin's lymphoma (NHL). Surgery, radiotherapy and chemotherapy (CT) have been used mostly in various combinations, but lately chemotherapy alone has emerged as an effective option. The purpose of this study is to evaluate efficacy of CT alone in treatment of primary GI-NHL and to compare the results with combined CT+surgery.

SETTING AND DESIGN

Retrospective analysis of case records of GI NHL patients.

MATERIALS AND METHODS

Over a 15-year period (1986-2000), 77 new cases of primary GI-NHL were registered at our center. GI-NHL was defined according to standard criteria. All patients received chemotherapy.

RESULTS

The median age was 32 years (Range 9-80). Endoscopy / CT guided biopsies were performed in 42% (32) of patients for the purpose of diagnosis. Laparotomy was done in 58% (45) of patients to establish a diagnosis or as primary or debulking treatment. Stomach and intestines were involved in 47% (36) and 53% (41) patients respectively. Early stage disease was present in 37% (29). Seventy eight percent of tumors were intermediate to high grade, 43% (33) received only CT while 57% (44) received CT+surgery. Five years EFS and OS were: 72% and 65% for all patients; 72% and 67% for CT only group; 60% and 64% for CT+surgery group (P=.05). Four patients died of neutropenic infection.

CONCLUSION

Organ-preservation strategy using chemotherapy alone (CT) can be successfully employed in a significant number of patients with primary GI-NHL.

Serial changes in bone marrow cellularity, reticulin fibrosis and microvessel density in patients with chronic myeloid leukemia (CML) in chronic phase treated with imatinib

6596

Background: Imatinib Mesylate, a BCR-ABL tyrosine kinase inhibitor produces sustained complete hematological response (CHR) in CML patients in chronic phase. There is a paucity of information on the effects of imatinib on the bone marrow (BM) morphology and angiogenesis. We evaluated the sequential changes in these parameters in 22 CML chronic phase patients treated with first line imatinib (400 mg) and compared with 10 controls (non-hematological malignancies). Methods: Trephine BM biopsies were evaluated by means of morphology, morphometry, Gomori’s stain and CD 34 staining. Reticulin fibrosis was graded from grade 1 to grade 4. Microvessel density (MVD) was calculated by counting the microvessels in hot spots (400 ×). Final value was mean of 10 fields. Total vascular area (TVA) was calculated by image analysis and expressed as percentage of the total area. Results: 22 patients were included in the study. Median age was 34 years (range 20–58 years). All patients attained a CHR at a median of 18 days. Major cytogenetic response was seen in 64%, minor response in 27% and no response in 9% of patients. Baseline BM cellularity was increased in all patents as compared to controls. The median cellularity at 6 months and 1 year was decreased to 60% and 50% respectively. The median grade of reticulin fibrosis at baseline was grade 3 as compared to controls (median grade 1). There was a significant decrease in reticulin fibrosis at 6 months and 1 year (median-grade 1, p=0.04). The median MVD at baseline was 8.25 (range 6–26) and was increased as compared to controls (median MVD-3.6). There was a significant decrease in MVD at 6 months and 1 year (median MVD-4.0, p=0.04). Similarly the TVA decreased from 6.2% at baseline to 4.3% at 1 year. These changes correlated with the cytogenetic responses. Two patients who had disease progression during therapy showed reversal in the bone marrow changes. Conclusions: Imatinib Mesylate produces significant effects on bone marrow morphometry and angiogenesis in patients with CML in chronic phase. There is a consistent decrease in bone marrow cellularity, reticulin fibrosis and microvessel density during therapy.

No significant financial relationships to disclose.

Fertility preserving radical cystectomy in a young female with malignant mesenchymal tumour of urinary bladder

Fertility preserving radical cystectomy has been reported in young males with leiomyosarcoma and transitional cell carcinoma but not in females. We present a case of 19-year-old lady with mesenchymal tumour of urinary bladder with myogenic differentiation who was managed with fertility preserving radical cystectomy. As the patient was just 19-year-old a consensus was made to preserve the internal genitalia (both the ovaries and uterus) in order to restore the fertility. Immunohistochemistry was compatible with mesenchymal tumour with myogenic differentiation. Adjuvant chemotherapy (Ifosfamide, CDDP and Etocid) was given. Patient is doing well at a follow-up of 6 months.

Primary malignant fibrous histiocytoma of the greater omentum

Primary malignant mesenchymal tumours of the greater omentum are rare. We report a 40-year old man with a painless abdominal lump of two months duration. At laparotomy, the mass was found to be arising from the greater omentum. A near-total omentectomy was done. Histological examination of the resected tumour revealed features consistent with malignant fibrous histiocytoma.

Superior vena cava syndrome

OBJECTIVE

In order to study the clinical profile of children presenting with superior vena cava syndrome (SVCS), case records of all children presenting with SVCS over a 10-year period were retrospectively analyzed.

METHODS

Twenty one children (20 males and 1 female) with a median age of 10.0 years (range 5.0 to 12.0 years) were detected to have an underlying hematological malignancy. T-cell acute lymphoblastic leukemia accounted for a major share (57%) in the underlying etiology; 33% of the subjects had non-Hodgkin's lymphoma (T-cell lymphoblastic lymphoma).

RESULT

No Patient required radiotherapy or urgent thoracotomy. Among survivors (n=11), who were alive and well at the time of writing this report, the median follow-up was 6.5 years, (range 0.5-9.6 years). T-cell ALL and lymphoblastic lymphoma are common underlying causes of SVCS in Indian children.

CONCLUSION

The value of diagnostic interventions performed under local anaesthesia and prebiopsy corticosteroids usage was found to be reassuring since long-term survival without disease is achievable.

Traditional Indian anti-diabetic plants attenuate progression of renal damage in streptozotocin induced diabetic mice

The purpose of the study was to investigate the effects of daily oral feeding Momordica charantia (MC) (200 mg/kg), Eugenia jambolana (EJ) (200 mg/kg), Mucuna pruriens (MP) (200 mg/kg) and Tinospora cordifolia (TC) extracts for 40 days on blood glucose concentrations and kidney functions in streptozotocin (STZ)-diabetic rats. Plasma glucose levels, body weight, urine volume and urinary albumin levels were monitored on every 10th day over a 40-day period while plasma creatinine levels were assessed at the beginning and end of experiment. Renal hypertrophy was assessed as the ratio between the kidney weight and total body weight. Plasma glucose concentrations in STZ-diabetic mice were reduced by the administration of extracts of MC, EJ, TC and MP by 24.4, 20.84, 7.45 and 9.07%, respectively (P<0.005 for MC, EJ, MP and P<0.05 for TC). Urine volume was significantly higher (P<0.005) in diabetic controls and MC, EJ, MP and TC treatment prevented polyuria (P<0.001, 0.0001, 0.01 and 0.001, respectively). After 10 days of STZ administration urinary albumin levels (UAE) were over 6 fold higher in diabetic controls as compared to normal controls. Treatment with MC, EJ, MP and TC significantly prevented the rise in UAE levels from day 0 to 40 in comparison to diabetic controls (P<0.0001, 0.0001, 0.05, 0.05, respectively). Renal hypertrophy was significantly higher in diabetic controls as compared to non-diabetic controls. MC and EJ partially but significantly (P<0.05) prevented renal hypertrophy as compared to diabetic controls. TC and MP failed to modify renal hypertrophy. Results indicate that these plant drugs should be studied further.

Primary malignant melanoma in ovarian cystic teratoma

BACKGROUND

Malignant degeneration of benign cystic teratoma of the ovary is rare. Occurrence of melanoma in an ovarian cystic primary teratoma in the absence of a demonstrable extraovarian primary is even rarer. We describe here one such case.

CASE

A 42-year-old nulliparous woman underwent laparotomy for a cyst in the right ovary. Histopathological examination of the specimen revealed malignant cystic teratoma with the presence of a melanoma component. There was no evidence of extraovarian primary melanoma on clinical examination. Two years later, she presented with lung metastasis and underwent left pneumonectomy. Histopathology confirmed metastatic melanoma. Postoperatively, she received combination chemotherapy using cisplatin and dacarbazine. She is on regular follow-up and continues to be disease-free, 18 months after treatment.

CONCLUSION

Primary malignant melanoma in cystic teratoma of the ovary is extremely rare. We could find only 19 such cases on review of the literature. Clinical presentation is similar to that of primary epithelial ovarian cancer. Surgery remains the mainstay of treatment. Use of cisplatin and dacarbazine may be considered in a patient with metastatic disease.

Prognostic utility of silver stained nucleolar organiser region counting in non Hodgkin's lymphoma

Silver stained Nucleolar Organiser Region (AgNOR) counting is a well established method of estimating the proliferative activity of a tumour. Their utility in prognostication in Non Hodgkin's Lymphoma (NHL) has not been fully investigated. We analysed hundred cases of NHL, all of which had a minimum of two and a half years of follow up, using histology by International Working Formulation (IWF) and their AgNOR scores. We found the IWF grading to have a good correlation with the outcome. The two and a half year survival for low grade NHL was 90 percent, for intermediate grade NHL was 47 percent and for high grade NHL was 30 percent. AgNOR scores correlated well with IWF grading and classification, with average AgNOR score of 1.82 (SD 0.34) in low grade NHL; 4.47 (SD 2.25) in intermediate grade NHL and 7.07 (SD 4.40) in high grade NHL. Over histology, AgNOR counting yielded additional prognostic information only in the diffuse small cleaved cell NHL (DSC), where finely dispersed NORs were seen. Of the 22 case of DSC included, 11 cases with AgNOR scores less than three had a much better outcome with 75 percent survival at two and a half years. Cases of DSC with AgNOR scores greater than three had a significantly worse outcome with only 25 percent survival at two and a half years (p=0.0103). Such sub-stratification could not be done in any other catergory of NHL using AgNOR scores. Thus, counting of AgNORs in lymphomas with finely dispersed NORs as in DSC is of prognostic value.

Cervical cancer metastatic to the breast: a case report and review of the literature

Metastasis to the breast from primary cervical cancer is rare. We describe one such patient, who developed breast metastasis 6 months after diagnosis. She was free of pelvic disease at the time of metastases but had evidence of lung involvement. She died of progressive disease 2 months later. Data on 23 patients collected from the literature via Medline are reviewed.

Ovarian carcinoma metastatic to the breast

We report the case history of a patient with ovarian carcinoma and bilateral breast metastases. The presence of metastases to the breast from a primary ovarian carcinoma, diagnosed at initial presentation, is a rarity.

Coexisting carcinoma and tuberculosis of stomach

We report a rare association of carcinoma and tuberculosis of the stomach. It is difficult to explain the simultaneous occurrence or a causal relationship of the two diseases.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Hodgkin's disease: a retrospective analysis of 15 years experience at a large referral centre

BACKGROUND

The prognosis of patients with Hodgkin's disease has improved significantly over the past two decades, primarily as a result of the development of curative combination chemotherapy. However, data on the presentation and results of treatment in Indian patients are scarce. We reviewed the clinical and pathological data and the treatment outcome of patients with Hodgkin's disease seen at our centre over the last 15 years.

METHODS

The case records of 289 patients diagnosed to have Hodgkin's disease at our centre between 1977 and 1992 were reviewed. Their clinical characteristics, treatment outcome and prognostic factors for survival were analysed.

RESULTS

The median age of the patients was 26 years with 30% being in the third decade. The male:female ratio was 4:1. The mixed cellularity histological subtype was the most common (68.5%), followed by nodular sclerosis (8.9%). 'B' symptoms were present in 73% of patients and 9.4% had bone marrow involvement. At the time of presentation, 70% of patients had advanced disease (stage III: 36%, stage IV: 34%). Complete response to treatment was obtained in 65.7% of patients while 17.3% had partial response. The predictors of decreased overall survival were age > 40 years, presence of 'B' symptoms, lymphocyte depletion histological subtype and stage IV disease. Disease-free survival was influenced by the presence of 'B' symptoms, bone marrow involvement and stage IV disease.

CONCLUSION

Hodgkin's disease in Indian patients has a distinct clinico-pathological profile. Combination chemotherapy has high response rates even in patients with advanced disease at presentation.

Non-Hodgkin's lymphoma presenting as a primary lesion in uterine cervix: case report

Non-Hodgkin's lymphoma (NHL) arising from extra nodal tissue and staying localized to that region is rare. Rarer still is primary NHL of the uterine cervix. We describe a patient with primary extra nodal NHL of the uterine cervix and vagina who was treated successfully with chemotherapy and radiotherapy. She is free of disease 17 months after treatment. Data of 52 patients collected from the literature (Medline, National Library of Medicine, Bethesda, MD) is reviewed.

Hodgkin's lymphoma of colon: an unusual cause of isolated splenic vein obstruction

A case of splenic vein obstruction due to infiltration by Hodgkin's lymphoma of the colon is reported. The patient presented with massive upper gastrointestinal hemorrhage and a lump in the abdomen. Laparotomy revealed a colonic tumor infiltrating the splenic vein, causing left sided portal hypertension.

Brain metastasis as the site of relapse in germ cell tumor of testis

BACKGROUND

Brain metastases occur in approximately 8-15% of patients with testicular germ cell tumors and invariably are associated with relapse at other sites, most commonly the lungs, or as a terminal event.

METHODS

The authors, from the Institute Rotary Cancer Hospital, a regional cancer center in northern India, did a retrospective analysis to determine how many previously treated patients had isolated cerebral metastasis develop.

RESULTS

Three of 123 patients with testicular germ cell tumor seen during a 6-year period starting in January 1986 had isolated cerebral metastasis develop during remission after initial treatment. Two patients who had pure seminoma were treated with radiation therapy and are alive and symptom free at 15 and 18 months. The third patient had a combined tumor, the major component of which was embryonal cell carcinoma, that required debulking surgery and radiation therapy, and the patient died with recurrent cerebral metastases.

CONCLUSIONS

Review of the literature reveals that although cerebral metastasis is well recognized in testicular cancer, particularly nonseminomatous germ cell tumor (NSGCT), it is invariably preceded by systemic metastasis. Cerebral metastasis is extremely rare as the sole and presenting feature of relapse. This complication must be recognized and treatment defined because it may become more frequent as patients survive for longer periods with modern disease management.

Primary Hodgkin's disease of small intestine: a report of two cases

Two patients with primary Hodgkin's disease of the small intestine are reported because of rarity of this condition. Both patients presented with primary intestinal symptoms and were diagnosed after surgical resection. The modalities of treatment and favorable long term survival are presented.

POEMS syndrome

A patient with peripheral polyneuropathy, hepatosplenomegaly, osteosclerotic myeloma in the ilium, hyperpigmentation and hypertrichosis is described. A diagnosis of POEMS syndrome was made. This is the first report of this syndrome from India.

Hodgkin's disease with pulmonary involvement

A patient of Hodgkin's disease with pulmonary involvement is described. Demonstration of Reed-Sternberg cells in the sputum confirmed the diagnosis of pulmonary involvement.

Lymphocytic infiltration of skin of Jessner-Kanof masquerading as borderline leprosy

A case of pseudolymphoma from India is being reported which had been masquerading for quite some time as a case of borderline leprosy. The patient has been having for the past 16 years, recurrent, occasionally pruritic, multiple, bilateral, erythematous papules and plaques, which on casual examination elsewhere had suggested leprosy.

Non-Hodgkin's lymphoma in northern India. A retrospective analysis of 238 cases

A retrospective analysis was performed of 238 patients, aged 12 years and older, with non-Hodgkin's lymphoma presenting to the All India Institute of Medical Sciences, New Delhi, India, between September 1975 and December 1982. Pathologic material was reviewed and classified according to the modified Rappaport classification. The most common histologic type encountered was diffuse histiocytic lymphoma (39%), followed by diffuse poorly differentiated lymphocytic lymphoma (29%), and diffuse mixed histiocytic and lymphocytic lymphoma (9%). Nodular lymphomas constituted 9% of all non-Hodgkin's lymphomas. A lower frequency of nodular lymphomas, a lower median age of onset (45 years), and a higher male to female ratio (4.5:1) as compared with Western countries was observed. Survival information on 90 patients revealed no effect of age, sex, stage of disease, and "B" symptoms on survival, whereas histologic diagnosis had a significant influence on survival (P less than 0.05). A median survival of 24 months in 58 patients receiving chemotherapy is comparable to that reported by other investigators.