Synchronous high-grade bladder carcinoma associated with chronic lymphocytic leukemia: A rare entity in Indian literature

B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is one of the common lymphoproliferative disorders with an increased risk of developing subsequent neoplasms of epithelial and mesenchymal origin. The decreased immunity and B-cell dysfunction in CLL probably accounts for this emergence of secondary malignancy. Breast, brain, skin and prostate tumors have been reported as usual coincident malignancies of CLL, while in occasional cases CLL may occur with malignancies of other solid organs, such as skin, lung, heart, and prostate. Synchronous CLL with urothelial carcinoma (UC) is an infrequent occurrence. We report this case because of its rarity in Indian literature and interesting hematological, immunophenotypic, histopathological, and cytopathological features of metastatic high-grade UC in a 61-year-old male with CLL

Cytomorphological Spectrum of Hepatic Nodular Lesions A Tertiary Care Centre Experience.

Background: FNAC is a very useful procedure for the diagnosis of various hepatic lesions. USG-guided FNAC offers good accuracy without major complications and minimal intervention at less cost, the only major contraindication being severe hemorrhage & vascular lesion. Although imaging techniques have helped greatly with the early and accurate diagnosis of liver abscess, the appearances are often non-specific. There is some overlap between the radiologic features of liver abscesses, HCC and metastases too. Tumors, primary or secondary, may undergo extensive necrosis, with the resultant radiologic image of the cavitatory neoplasm mimicking abscesses; abscesses are accompanied by proliferative reactive changes, making radiologic differentiation from a neoplastic process almost impossible. In these situations, FNAC plays an essential complementary role. Material and Methods: All patients, irrespective of age and sex, who presented to the hospital from January 2011 to June 2013 with nodular liver lesions diagnosed clinically or radiologically, with normal range of prothrombin time (International normalized ratio- INR) were subjected to fine needle aspiration under radiological guidance. Smears made were stained with toluidine blue for rapid onsite evaluation (ROSE) for adequacy of diagnostic material. Hematoxylin and Eosin (H&E), Giemsa stain and Papanicolaou stain were done as per protocol. Results: Of the total aspirates, 22.5% (36 cases) were benign, 63.75%(102) were malignant, 13.75% (22) non-representative as they contained only few scattered hepatocytes and blood, which was inadequate for final opinion. FNAC was of help in diagnosing liver lesions successfully in 86.25% of cases. Conclusion: USG guided FNAC has proved to be a fairly precise & minimally invasive technique in diagnosis of hepatic lesions as the procedure is simple, economical and easily available. The results are obtained quickly without serious complications related to the procedure. In a nutshell, FNAC is a highly accurate diagnostic tool with high sensitivity & specificity.

Paratesticular papillary serous cystadenocarcinoma: A rare entity in Indian population.

Ovarian-type surface epithelial carcinomas of testis and paratestis are very rare. These tumors develop from mesothelial inclusions or abnormalities in the development of coelomic epithelium. The diagnosis of these lesions can be difficult, both clinically and radiologically, as morphological, immunohistochemical and ultrastructural features overlap with serous tumors arising in the female genital tract. The pathologist should be aware of the histopathological features and immunostains which help in reaching defi nite diagnosis. To the best of our knowledge only one such case has been reported in Indian literature. We hereby report a case of young male with this unusual lesion diagnosed on histopathology.

Multifocal hemangioendotheliomas of bone mimicking metastases.

Hemangioendotheliomas are rare vascular tumors that can arise from soft tissue or bone. The former comprises hemangioma, epithelioidhemangioma, hemangiomatosis and massiveosteolysis or Gorham’s disease (which mimics malignantneoplasm due to aggressive osteolytic destruction). The rarer malignant counterparts are epithelioidhemangioendothelioma, hemangioendothelioma and angiosarcoma in increasing order of malignancy. The diagnosis of these lesions is diffi cult both clinically and radiologically. Hereby we report an unusual case which was mistaken for metastasis and was diagnosed with the help of histopathology.

Pathological Spectrum of Urinary Bladder Tumours.

Objective: Recently few reports have reported high incidence of urinary bladder cancer in the Punjab region in India while others have shown high inorganic arsenic levels in the ground waters of the same region. Furthermore, the malignancy of the urinary bladder contributes significantly to the morbidity, mortality and thus adding to the burden on the healthcare and society. Materials and Methods: A retrospective analysis over a period of 4 years was undertaken to review all urinary bladder tumour biopsies, transurethral resection of bladder tumours (TURBT) and cystectomy specimens to study the histomorphological spectrum of the urinary bladder cancers according to the “WHO Classification of Tumours of the Urinary Tract”. The records of Pathology department were probed for urinary bladder specimens. Further demographic characteristics, clinical diagnosis, cystoscopic findings were retrieved from the patient’s files from the record section. The tissue section slides were then reviewed and results recorded. Results: In our cohort, 144 patients were from State of Punjab with about 50% belonging to the city where our hospital is located. Cystoscopic revealed papillary appearance in 112 out of 135 patients. Moreover, 111 cases (82.22 %) were unifocal. Urothelial neoplasms were the most common bladder tumours and Invasive Urothelial Carcinomas constituted the bulk of these. Conclusions: Our cohort comprised of relatively younger population with dominance of high grade urothelial carcinoma showing features of invasion on microscopy. Further, we observed that WHO/ISUP classification to be comprehensive and universally acceptable. The role of arsenic as a causative agent in urothelial neoplasms needs to be studied further.

Role of fiberoptic bronchoscopy and utility of bronchial washings and brushings in the diagnosis of lung diseases.

Transbronchial lung biopsy via fiberoptic bronchoscope is an extremely useful technique by which bronchial as well as lung biopsies along with brushings and washings can be easily and safely taken.1 Fiberoptic bronchoscopy (FOB) was performed and biopsies were done in 250 patients. In addition, bronchial brushings and washings were also taken in 140 and 115 cases, respectively. Adequate material was obtained in 242 cases. The cases were broadly classified into neoplastic and nonneoplastic categories. Malignancies and specific granulomatous diseases, tuberculosis and sarcoidosis were the main diseases diagnosed. Brushings showed a sensitivity of 88.2% and a specificity of 98.9% for the diagnosis of neoplasms. On the other hand, washings had only a 34.9% sensitivity and a 98.6% specificity in diagnosing neoplastic disorders. We concluded that FOB is a safe and effective tool in the diagnostic work-up of suspected malignancies and neoplastic lung diseases.

How sustained is sustained viral response in patients with hepatitis C virus infection.

Background Sustained virological response (SVR) is achieved in a high proportion of patientswith chronic hepatitis C infection, particularly those with genotype 2 or 3 HCV infection. However, data on long-term durability of virological response in patients who achieve SVR are limited. Aim To evaluate the long-term durability of virological response in patients who have achieved SVR with interferon-based combination therapy. Methods One hundred patients with chronic HCV infection who had obtained SVR after IFN and ribavirin combination therapy were followed up for up to 8 years with annual HCV RNA testing. Results During a followed up of 6 months to 8 years, 8 of 100 patients with initial SVR developed late relapse of HCV infection. Relapse was more common in patients who had cirrhosis (5/28 [18%] vs. (3/72 [4%] with no cirrhosis; p=0.037). Conclusion SVR is durable in most patients, but some patients do have late relapse; long term follow up may be particularly important in a subset of patients with HCV infection who have liver cirrhosis.

Efficacy and safety of pegylated IFN alfa 2b alone or in combination with ribavirin in thalassemia major with chronic hepatitis C.

Background Treatment of HCV infection in patients with thalassemia major (TM) is limited by the lack of large clinical trials and concerns about ribavirin-induced hemolysis. Methods We conducted a prospective, randomized, openlabel study to determine efficacy and tolerability of pegylatedinterferon alfa 2b (1.5 μg/kg/week) alone (group A) or with ribavirin (12–15 mg/kg/day; group B) in patients with TM and chronic HCV infection. Patients with genotype 1 or 4 HCV were treated for 48 weeks and those with genotype 3 or 2 HCV for 24 weeks. Early viral response (EVR; after 12 weeks of treatment), end-of-treatment virological response (ETR) and sustained virological response (SVR; 6 months after stopping therapy) were assessed. Results Of 40 patients, 20 each were allocated to the two treatment groups. EVR rates in group A and B were 15 (75%) and 18 (90%), respectively. ETR occurred in 17/20 (85%) patients in each group. SVR occurred in 8 (40%) patients in group A and 14 (70%) in group B. Blood transfusion requirements increased in one patient in group A and four patients in group B. One patient in group A had severe sepsis and one in group B had nephrotic syndrome. Two patients in each group required reduction in drug dose. Conclusions In patients with TM and chronic HCV infection, pegylated interferon alfa 2b and ribavirin combination therapy achieves a higher SVR rate than pegylated interferon alone, and is well tolerated except for an increase in blood transfusion requirement.

Cyclosporine in the treatment of severe steroid refractory ulcerative colitis: a retrospective analysis of 24 cases.

BACKGROUND: Cyclosporine A (CsA) has been found to be the first successful therapy used in the recovery of patients with steroid-refractory ulcerative colitis (UC). However, the long-term benefits of cyclosporine remain questionable. We report our results on the use of CsA in patients with severe steroid-refractory UC. METHODS: The records of all patients with steroid refractory UC treated with CsA from January 2003 to December 2007 were reviewed. Demographics, clinical characteristics of the disease, responsiveness to CsA, complications arising from the treatment and the need for surgery were recorded for all patients. RESULTS: Of 146 admissions of severe UC, 24 patients who were steroid refractory (mean age 41.7 years; 11 men) received intravenous cyclosporine (4 mg/kg/day) for mean of 6.63 days (range 1-7), followed by oral CsA for a period of 3 months. All patients had failed to respond to intravenous hydrocortisone given for 7 days. Four patients required a colectomy immediately, three of whom failed to respond to CsA, and one had convulsions following drug administration. Nineteen of the 24 patients (79%), in whom a colectomy was avoided during the early stages of their treatment, were followed up for a mean of approximately 38 months (range 12-62 months). Three patients required surgery on follow up; one was operated at day 94, another in the second year and one in the third year. Overall, 16 of 24 patients (67%) remained colectomy-free. The main side-effects observed included infections, tremors, paresthesias, headache, hypertension, hypertrichosis and peripheral neuropathy. Three of seven patients who had to undergo surgery died within 2 weeks. CONCLUSIONS: Our study shows that surgery can be avoided in two-thirds of patients with steroid refractive severe UC. However, the drug toxicity and mortality are significant.

Coexistence of chronic calcific pancreatitis and celiac disease.

Coexistence of celiac disease with chronic calcific pancreatitis is rare. We describe a 26-year-old woman with chronic calcific pancreatitis in whom non-response to treatment was due to celiac disease.

Pegylated interferon alfa 2b and oral ribavirin in patients with HCV-related cirrhosis.

BACKGROUND: The treatment of hepatitis C virus (HCV)-related cirrhosis is difficult due to high frequency of adverse effects. We retrospectively reviewed the case records of patients with HCV cirrhosis to evaluate the efficacy and tolerability of pegylated (peg) interferon and ribavirin treatment in these patients. METHODS: Medical records of 28 patients with HCV-related compensated cirrhosis were reviewed. The treatment protocol was a combination therapy of peg interferon alfa-2b (1 microg/Kg/week) plus oral ribavirin (10-12 mg/Kg/day). Primary endpoint was sustained virological response, with additional endpoints of drug tolerance, clinical or biochemical worsening and death. RESULTS: End-of-treatment virlogic response was seen in 24 of 28 patients (85%) and sustained virologic response in 15 of 28 (53%) patients. Biochemical end-of-treatment response and sustained response were seen in 20 and 16 patients (71% and 57%), respectively. Treatment had to be stopped in 3 patients due to decompensation of liver status in two and drug intolerance in one, while dose modification was required in two patients. CONCLUSIONS: Combination therapy with peg interferon plus ribavirin seems effective in patients with liver cirrhosis. High relapse rate, poor biochemical recovery and possibility of decompensation are issues that need to be kept in mind.

Prevalence of celiac disease among siblings of celiac disease patients.

AIMS: To determine the prevalence of celiac disease (CD) in siblings of patients with this disease in Punjab, where wheat is the staple diet. METHODS : Families of 80 patients with CD diagnosed as per modified ESPGAN criteria were offered family screening. Their siblings aged 2-15 years were tested for serum IgA anti-tissue transglutaminase antibody (anti-tTG) antibody. Those with positive or borderline test and some of those with negative test underwent endoscopic duodenal biopsy. Siblings with characteristics histological findings and showing improvement on follow-up were labeled as having celiac disease. RESULTS: Of the 63 siblings of 48 index cases studied, 15 tested positive for anti-tTG; of these 13 had celiac disease. Three tested borderline for anti-tTG; none of them had CD. Of the 45 anti-tTG-negative subjects, two agreed to undergo biopsy; one of these had features of CD. Overall, 14 of 63 (22%) siblings had CD, including 8 who had no symptoms suggestive of CD. CONCLUSIONS: CD is common among siblings of patients with CD in Punjab and may be asymptomatic.

Coexistence of Takayasu's arteritis with ulcerative colitis.

The association of ulcerative colitis with Takayasu's arteritis is rarely reported. The occurrence of the two together is possibly related to a common pathophysiology involving alteration in immune mechanisms. Takayasu's arteritis is more prevalent in Japan and South East Asia whereas Ulcerative Colitis is more in Western countries. The coexistence of these two diseases is uncommon and hence this report.