Diagnosis and treatment of Hodgkin's lymphoma: at times a challenge

Hodgkin's lymphoma has been traditionally defined as a hematopoietic neoplasm composed of diagnostic Reed-Sternberg cells. More than 70% of the cases involve cervical or supraclavicular lymph nodes. Isolated sub-diaphragmatic lymphadenopathy or organ involvement is rare. We present the case of Hodgkin's lymphoma in a 51 years old female, who presented with obstructive jaundice and lymphadenopathy, empirically treated previously as a case of tuberculosis. Chemotherapy with modified ABVD protocol was given with dose modification according to LFT's. Her liver functions returned to normal levels after the first cycle. The main purpose of reporting the case is to stress definitive diagnosis of the disease before initiating treatment and the modified chemotherapy regimen used in this infrequent presentation of the disease

Solid neuroendocrine carcinoma of the breast

Primary neuroendocrine carcinoma of the breast is a rare disease that accounts for less than 5% of all cancers arising from the breast. The tumour cells stain positively for chromogranin and synaptophysin. This report describes the occurrence of infiltrating ductal carcinoma of breast with neuroendocrine differentiated tumour in 37 year old female. Early small cell neuroendocrine cancer of the breast that is treated with surgery and adjuvant chemotherapy shows an increased disease-free survival. She is planned for anthracycline/cyclophosphamide based chemotherapy followed by etoposide/platinum based chemotherapy. As her tumour showed ER/PR positivity, she will be given hormonal therapy subsequently, however, more extensive review is required to define a standard treatment protocol for this rare neoplasm.

Gamut of hepatocellular carcinoma at oncology department, Sheikh Zayed hospital, Rahim Yar Khan

Background: Hepatocellular carcinoma is ranked as third most cause of death from cancer in world

Objective: The objective of this study was to review predisposing factors among patients with Hepatocellular carcinoma [HCC] at a tertiary care centre in past two years

Material and Methods: This Descriptive study was conducted on patients who had proven HCC by histopathology or tumor marker were reviewed retrospectively and data for January 2009 to December 2010 was included. Demographic features were noted and positivity for hepatitis serology, presence of cirrhosis, level of alpha-fetoprotein, tumour size and distribution of liver lesions were noted

Results: A total of 192 patients were found to have histopathology and tumor marker proven HCC. Males were 149 [77.6%] vs females 43 [22.4%]. Hepatitis B surface antigen was noted to be positive in 27[14%] patients, and HCV was found to be positive in 138 [72%] patients. Patients with dual hepatitis [HBV+HCV] were 16 [08%] and in remaining 11 [06%] patients the etiology was unknown. Alpha fetoprotein level was highly elevated in 154 [84%] and Cirrhosis was noted in 134 [70%] patients. 117 [61%] patients had multicentric distribution

Conclusion: Hepatocellular carcinoma in this area, is related to hepatitis C virus infection in majority of the patients. A large number have underlying cirrhosis, multicentric and advanced disease at presentation. The disease is seen in the 5th and 6th decade and predominantly among males

Gated MIBI myocardial spect showing balanced ischemia and global hypokinesia in patient having thrombus in basal segment of dominant circumflex system blocking both left anterior descending and circumflex artery

Myocardial perfusion imaging [MPI] is a powerful diagnostic and prognostic tool for evaluating coronary artery disease [CAD]. Gating myocardial perfusion gives important diagnostic and prognostic information. This 43 years old patient was referred for cardiac scan. Exercise stress test showed > 2mm horizontal ST segment depression. Cardiac scan was normal except for left ventricular cavity dilatation on stress images. Gated images showed global hypokinesia and increased end-diastolic volume. Patient was suspected to have balanced ischemia and was referred for Angiography. Angiography showed total occlusion with no flow in proximal Left Anterior Descending Artery and distal circumflex artery. It is very important to evaluate symptomatic patients and patients with risk factors carefully with normal myocardial perfusion scan

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy

Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi. One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings. A total of 105 patients [77 male and 28 female] with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 [84%] patients. The commonest diagnosis was ulcerative colitis, which was found in 48 [46%] patients. It was followed by colorectal carcinoma, 11 [10%] patients, and non-specific colitis, 9 [8%] patients. Other less frequent findings were colonic diverticuli, 7 [6%] patients, solitary rectal ulcer, 5 [4%] patients, colonic polyps in 3 [2.5%] patients and one case each of telangiectasia and Crohn's disease. Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region

Dual phase MIBI scintigraphy in diagnosis of parathyroid adenoma followed by ultrasound guided percutaneous alcoholic ablation

Primary Hyperparathyroidism [HPT] is an inappropriate hyper secretion of parathyroid hormone [PTH]. Primary HPT is caused by parathyroid adenoma in 80-85% of patients. Clinical manifestations are kidney stones, abdominal groans, painful bones, psychic moans, and fatigue overtones. Ultrasonography is widely used in suspected cases for localization of parathyroid adenoma. There is considerable intra-observer variation and it is difficult for ultrasound alone to differentiate parathyroid lesion form that of thyroid. Dual phase Tc-99m MIBI scinitigraphy for detection of parathyroid adenomas has sensitivity and specificity values ranging from 82% to 100% and from 89% to 100%, respectively. Percutaneous ethanol injection for parathyroid glands can be applied effectively in selected cases when surgery is unadvisable either for technical reasons e.g., recurrence of hyperplastic glands in the neck after subtotal surgery or intrathyroideal parathyroid tumors or the poor clinical state of the patient