Showing papers by "Tata Memorial Hospital published in 2003"

Craniofacial surgery for malignant skull base tumors: report of an international collaborative study

Abstract: BACKGROUND Malignant tumors of the skull base are rare. Therefore, no single center treats enough patients to accumulate significant numbers for meaningful analysis of outcomes after craniofacial surgery (CFS). The current report was based on a large cohort that was analyzed retrospectively by an International Collaborative Study Group. METHODS One thousand three hundred seven patients who underwent CFS in 17 institutions were analyzable for outcome. The median age was 54 years (range, 1–98 years). Definitive treatment prior to CFS had been administered in 59% of patients and included radiotherapy in 367 patients (28%), chemotherapy in 151 patients (12%), and surgery in 523 patients (40%). The majority of tumors (87%) involved the anterior cranial fossa. Squamous cell carcinoma (29%) and adenocarcinoma (16%) were the most common histologic types. The margins of surgical resection were reported close/positive in 412 patients (32%). Adjuvant postoperative radiotherapy was received by 510 patients (39%), and chemotherapy was received by 57 patients (4%). RESULTS Postoperative complications were reported in 433 patients (33%), with local wound complications the most common (18%). The postoperative mortality rate was 4%. With a median follow-up of 25 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 54%, 60%, and 53%, respectively. The histology of the primary tumor, its intracranial extent, and the status of surgical margins were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS CFS is a safe and effective treatment option for patients with malignant tumors of the skull base. The histology of the primary tumor, its intracranial extent, and the status of surgical margins are independent determinants of outcome. Cancer 2003;98:1179–87. © 2003 American Cancer Society. DOI 10.1002/cncr.11630

Concurrent methylation of multiple genes in childhood ALL: Correlation with phenotype and molecular subgroup.

Abstract: Multiple genes have been shown to be independently hypermethylated in lymphoid malignancies. We report here on the extent of concurrent methylation of E-cadherin, Dap-kinase, O(6)MGMT, p73, p16, p15 and p14 in 129 pediatric ALL cases. While most of these genes demonstrated methylation in a proportion of cases, O(6)MGMT, p16 and p14 were infrequently methylated (11, 7 and 3%, respectively). Methylation of at least one gene was found in the vast majority (83%) of cases. To determine the extent and concordance of methylation we calculated a methylation index (MI=number of methylated genes/number of studied genes) for each sample. The average MI was 0.28, corresponding to 2/7 methylated genes. MI was correlated with standard prognostic factors, including immunophenotype, age, sex, WBC and presence of specific translocations (TEL-AML1, BCR-ABL, E2A-PBX1 or MLL-AF4). We determined that children >/=10 years old and children presenting with high WBC (>/=50 x 10(9)/l) both associated with a higher MI (P<0.01 and <0.05, respectively). T-ALLs demonstrated a lower MI (median=0.17) than precursor B ALLs (median=0.28). Among the different molecular subgroups, MLL-ALLs had the highest MI (mean=0.35), while ALLs carrying the t(1;19) had the lowest MI (mean=0.07). The most common epigenetic lesion in childhood ALL was methylation of E-cadherin (72%) independent of the molecular subtype or other clinicopathological factors.

Long-term results of orthotopic neobladder reconstruction after radical cystectomy.

Abstract: Objective To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. Patients and methods Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. Results In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36–144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. Conclusions Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.

Haematologic and immunophenotypic profile of acute myeloid leukemia: An experience of Tata Memorial Hospital

Abstract: OBJECTIVES : To study the hematologic and immunophenotypic profile of 260 cases of acute myeloid leukemia at diagnosis. MATERIAL AND METHODS : This is a retrospective analysis of 260 cases of AML diagnosed at our institution between 1998 and 2000. Diagnosis was based on peripheral blood and bone marrow examination for morphology cytochemistry and immunophenotypic studies. SPSS software package, version 10, was used for statistical analysis. RESULTS : Seventy-six percent of our cases were adults. The age of the patients ranged from one year to 78 years with a median age of 27.2 years. There were 187 males and 73 females. The commonest FAB subtype, in both children and adults, was AML-M2. The highest WBC counts were seen in AML-M1 and the lowest in AML-M3 (10-97 x 10(9)/L, mean 53.8 x 10(9)/L). The mean values and range for hemoglobin was 6.8 gm/l (1.8 gm/l to 9.2 gm/l), platelet count 63.3 x 10(9)/L (32-83 x 10(9)/L), peripheral blood blasts 41.4% (5 to 77%) and bone marrow blasts 57.6% (34-96%). Myeloperoxidase positivity was highest in the M1, M2 and M3 subtypes. CD13 and CD33 were the most useful markers in the diagnosis of AML. CD14 and CD36 were most often seen in monocytic (38%) and myelomonocytic (44%) leukemias. Lymphoid antigen expression was seen in 15% of cases. CD7 expression was the commonest (11%). CONCLUSION : AML accounted for 39.8% of all acute leukemias at this institution. The most common subtype was AML-M2. Myeloperoxidase stain was a useful tool in the diagnosis of myeloid leukemias. CD13 and CD33 were the most diagnostic myeloid markers.

Transoral laser surgery for early glottic cancers.

Abstract: Objective To demonstrate the oncologic safety of transoral endoscopic laser surgery in early glottic cancers. Patients The study included 107 patients with early glottic cancers. The disease was in situ in 21 (19.6%) and infiltrative in 86 (80.4%), of which 52 (48.6%) were stage T1a, 17 (15.9%) were T1b, 13 (12.1%) were T2, and 4 (3.7%) were TX lesions. One hundred three patients (96.3%) were treated primarily, whereas 4 patients (3.7%) were operated on after radiotherapy failure. Anatomically, 77 lesions (72.0%) involved the anterior or middle third of the vocal cord; 14 lesions (13.1%) involved a single cord and the anterior commissure; 4 "horseshoe" lesions (3.7%) involved both cords and the anterior commissure; 7 lesions (6.5%) involved the posterior third of the cord reaching the vocal process of the arytenoid; and 5 cases (4.7%) involved both cords separately. Results There were 17 (15.9%) local recurrences (10 among patients with single cord lesions, 5 among patients with cord and anterior commissure lesions, and 2 among patients with lesions involving both cords), and 1 regional recurrence. One hundred one patients (94.4%) were alive and disease free at a median of 40.7 months. Three patients (2.8%) were alive with disease. One patient (0.9%) died of other causes. Two patients (1.9%) died of a second primary cancer. The overall larynx preservation rate was 92.5%. Recurrence-free survival was 86.6% at 2 years, 84.1% at 5 years, and 78.1% at 10 years. Conclusion Transoral laser surgery is an oncologically safe, function-preserving modality for treatment of early glottic cancers.

Benign Metastasizing Meningioma

Abstract: Meningiomas represent about one sixth of all primary neoplasms of the central nervous system. They rarely metastasize outside the intracranial compartment. There are no clear criteria to identify the subset of aggressive tumors which recur locally or metastasize. Histological tumor grade is the most important predictor of recurrence or metastases. We report an unusual case of recurrent metastasis in an extrapleural location and review the literature. Our patient developed recurrent thoracic metastases from an intracranial benign meningioma after a disease-free interval of 8 years. She was successfully managed by wide excision of the metastasis and is currently asymptomatic.

A multicenter Phase I safety study of intratumoral photoactivation of talaporfin sodium in patients with refractory solid tumors

Abstract: BACKGROUND Photodynamic therapy (PDT) currently is approved for the palliative treatment of malignancies of the aerodigestive tract using laser-activated porfimer sodium A new approach has been developed, based on intratumoral placement of a nonlaser light device that activates talaporfin sodium, that may expand the use of PDT to include a broader range of treatment-resistant malignancies The safety of this approach was assessed in a Phase I study in patients with locally advanced, refractory tumors METHODS Twenty-one patients with radiation-resistant or chemotherapy-resistant or inoperable malignancies were enrolled in four cohorts representing four light doses Patients were treated with a single intratumoral light device and a fixed photosensitizer dose Safety assessments were based on review of adverse events (AEs) and serious adverse events (SAEs), and independent evaluation of computed tomography (CT) images RESULTS The observed occurrence of treatment-related AEs and SAEs was minimal No cutaneous phototoxicity was observed in any patient The overall observed tumor response rate was 33% CONCLUSIONS Photoactivation of talaporfin sodium using intratumoral nonlaser light was found to be safe in the patient population of the current study at all light dose levels tested Cancer 2003 © 2003 American Cancer Society DOI 101002/cncr11708

Use of banked tissue in plastic surgery.

Abstract: The availability of safe and reliable, banked tissues in India has enabled the use of human bone allografts as a viable alternative to autografts in reconstructive surgery. Lyophilised, irradiated bone grafts were used in 2 cases of rhinoplasty, a case of hemifacial atrophy, and as a chin implant. In the patient with revision rhinoplasty the rib graft was resorbed. The patient with hemifacial atrophy developed seroma and infection in the zygomatic and infraorbital area and the rib graft had to be removed. The graft from the same rib that was placed over the mandible was retained well and incorporated completely. The iliac crest cortico-cancellous grafts did well in the second case of augmentation rhinoplasty and in the augmentation of chin. The primary objective of reconstructive surgery in the treatment of burns, non-healing wounds and pressure sores is to remove the dead tissue and restore the continuity of the skin without delay. Lyophilised, irradiated, human amnion is a temporary biological dressing conveniently available off-the-shelf. It was used in twenty four patients with burns, eight patients with bedsores and six patients with non-healing ulcers mainly on the foot. The total surface areas of burns sustained were from 2% to 40%. The burns ranged from second degree to deep third degree burns. Amnion was not used in patients with infected third degree burns. The amnion provided good biological cover in all the patients. It was easy to handle and apply, and provided pain relief. The duration of healing varied depending on the extent and depth of the wound and the amount of exudate. The superficial bedsores healed with a single application of amnion. Reduced exudate, healthy granulation tissue and enhanced epithelisation were observed following application of amnion.

Frequencies of the major subgroups of precursor B-cell acute lymphoblastic leukemia in Indian children differ from the West.

Abstract: Frequencies of the major subgroups of precursor B-cell acute lymphoblastic leukemia in Indian children differ from the West

Medical decompressive therapy for primary and metastatic intracranial tumours

Abstract: Summary Medical decompressive therapy (MDT) with corticosteroids and mannitol is often used in patients with primary or metastatic brain tumours. This review highlights the lack of sound evidence regarding the indications and dosage schedule of steroids, prolonged use of which may cause debilitating complications. The available evidence supports the short-term use of MDT for raised intracranial pressure or progressive neurological deficits, but in the absence of these symptoms, MDT is not recommended for stable focal deficits, abnormal higher mental functions, seizures, or as prophylaxis during cranial irradiation. A practical stepladder guideline (based on symptom severity) is proposed with a starting daily dexamethasone dose of 6 mg for non-severe headache and or vomiting; 12 mg for progressive focal neuro logical deficit with or without non-severe headache or vomiting; and 24 mg dexamethasone with mannitol for severe headache, vomiting, or altered consciousness. Depending on the clinical response, dose can be increased to the next step(s) or tapered every 48 h (more slowly in patients who are dependent on steroids). A scheme for the assessment of efficacy and toxicity prevention is also proposed. The proposed guidelines may be used as a template for further clinical research.

Sentinel-node biopsy in breast cancer.

Abstract: Axillary lymph node dissection (ALND) is an important tool in staging patients with breast cancer. However, this procedure has several sequelae and complications and improvement in early diagnosis has led to an increasing number of cases of ALND in which axillary nodes are found to be negative. Sentinel node (SN) biopsy appears to be a less invasive alternative to ALND. The aim of the present study was to assess whether SN is a reliable indicator for axillary staging. We studied 126 consecutive patients with T1-T2 breast cancer and clinically negative axilla. In each case, 30-70 MBq of 99mTC-labelled colloidal albumin was injected subdermally close to the tumour and SN was visualised by lymphoscintigraphy. Surgery was performed 24 h after injection and the SN was removed under the guidance of a gamma ray-detecting probe. ALND was then undertaken in all cases. A histopathologic examination of the SNs was then made and the findings compared with the status of the other axillary nodes. SNs were identified and biopsied in 115/126 patients (91.3%) and correctly predicted the axillary status in 110/115 cases (95.6%). In five cases (4.4%), SNs were found to be negative, but other axillary nodes were positive. Our data confirm that SN biopsy is a good method for staging the axilla in patients with breast cancer. However, before SN biopsy can replace ALND in daily clinical practice, some technical aspects must be standardized, and clinical trials are required in order to clarify the prognostic impact of false-negative cases.

Use of a reduced-intensity conditioning regimen for allogeneic transplantation in patients with chronic myeloid leukemia.

Abstract: Reduced-intensity conditioning that harnesses the potential of a graft-versus-tumor (GVT) effect has been proposed as an alternative to conventional myeloablative allogeneic stem cell transplantation. The primary aim is engraftment and this can be achieved with minimal immunosuppression. In this report, we describe the use of such regimens for CML in 17 patients who received human leukocyte antigen (HLA)-matched sibling allografts. Conditioning was with fludarabine, antithymocyte globulin (ATG) and busulfan for the first 11 patients, whereas fludarabine, busulfan and TBI were used for the remaining six patients. Engraftment was prompt in most of the cases. Complications and need for supportive therapy in the immediate post-transplant period were reduced drastically. Only two patients (both in the TBI group) died within the first 100 days. Acute graft-versus-host disease (GVHD) grade II-IV was seen in seven patients. Complications occurred later on. Chronic GVHD was observed in 11/17 patients. Lung infection and GVHD were the major killers. In surviving patients, after a median follow-up of 30 months (range 37-21 months), 6/17 (35.3%) are alive. Five are disease free and one patient is still in relapse even after a second donor lymphocyte infusion. Total treatment time and cost were more than with conventional transplants. We conclude that reduced-intensity transplantation still requires further refinement.

Dance of live adult filarial worms is a reliable sign of scrotal filarial infection.

Abstract: Objective. To determine the value of the filarial dance sign as a diagnostic sign of scrotal filarial infection and to recognize unsuspected scrotal filariasis by this sign. Methods. Eight symptomatic patients in whom the filarial dance sign was shown on high-resolution ultrasonography were studied, investigated, and followed after treatment with diethylcarbamazine citrate. Two patients underwent fine-needle aspiration. Results. Multiple foci (nests) of motile (live) filarial worms were observed in most patients Fine-needle aspiration of the dilated lymphatic vessels in 2 patients confirmed the presence of microfilariae. Five of 8 patients had a favorable response to treatment with diethylcarbamazine citrate. Conclusions. High-resolution ultrasonography is a useful technique for diagnosing scrotal filariasis in symptomatic patients and is very useful in the follow-up period for assessing the response o 4 worms to treatment.

Expression of enhancing factor/phospholipase A2 in skin results in abnormal epidermis and increased sensitivity to chemical carcinogenesis.

Abstract: Enhancing factor (EF), a growth factor modulator, is the mouse homologue of human secretory group II phospholipase A2. EF exhibits growth-promoting activity in vitro, in the presence of epidermal growth factor, and also brings about phenotypic transformation of normal cells. In order to ascertain the role of EF in vivo, a human keratin-14 promoter was used to drive the expression of EF ectopically to squamous epithelial cells. The founder mouse and its progeny showed abnormal whiskers and a scaly, beaded tail. In these mice, keratinization pattern of the epidermis was disturbed and parakeratosis and acanthosis were noted. The transgenic mice, TgK14-EF, expressed EF in the suprabasal layers of tail epidermis as well as in the epithelial cells of hair follicle and sebaceous glands of skin. Expression of EF along with hyperplasia was also observed in other squamous epithelia such as buccal mucosa, tongue and oesophagus. TgK14-EF mice homozygous for the transgene showed delayed and scanty hair growth although the mice were healthy and fertile. The hemizygous TgK14-EF mice were sensitive to a two-stage chemical carcinogenesis and developed a higher number of papillomas than their normal littermates over the course of the experiment. The conversion rate of papilloma to carcinoma was two fold higher in the transgenic mice.

Ochronotic arthropathy: arthroscopic findings in the shoulder and the knee.

Abstract: Ochronotic arthropathy is a disorder resulting from the deposition of homogentisic acid derivatives in the articular cartilage and the menisci. Large joints of the appendicular skeleton are preferentially affected. The clinical picture resembles that of degenerative joint disease. We present the arthroscopic findings in the shoulder and the knee in a 40-year-old man with ochronotic arthropathy and discuss the role of arthroscopy in the diagnosis and management of this rare metabolic disorder.

Setting up a Tissue Bank in India: The Tata Memorial Hospital Experience.

Abstract: In India, the procurement of tissues for transplantation is governed by the Transplantation of Human Organs Act, 1994. However, although this law exists, it is primarily applied to organ transplantation and rules and regulations that are specific to tissue banking have yet to be developed.

Radical radiation vs surgery plus post-operative radiation in advanced (resectable) supraglottic larynx and pyriform sinus cancers: a prospective randomized study

Abstract: Aim: Survival in head and neck cancers reflect loco-regional control. With an aim of organ and function preservation the present study was undertaken to compare local failure and survivals. Material and methods: Between August 1991–December 1995, 72 patients with resectable advanced supraglottic cancers, were randomized to radical surgery followed by post-operative radiation therapy (Sx+PORT) (Arm I) or radical radiation therapy followed by salvage surgery (RRT+/−SSx) (Arm II). Results: Sixty-four of 72 patients were evaluable, 55 were T3 (86%) and 9 were T4 (14%) tumors. In Arm I ( n =35) with a mean follow-up of 24 months (2–86 months), 21 patients were alive without disease. Six patients had recurrence, one each at local and tracheostomy stoma, four had nodal recurrence only, and two developed 2nd primary in soft palate/tonsil and parotid at 15 and 18 months respectively. In Arm II ( n =29), with a mean follow-up of 24 months (3–81 months), 14 patients were alive without disease. Thirteen patients had recurrence, eight had local (one patient had persistent disease), two nodal only, three loco-regional and two patients developed distant metastasis (lung). One out of eight local recurrence and 2/2 nodal recurrences were salvaged with Sx. There was a significant difference in disease-free survival between the two treatment arms, DFS (5 years) of 70% in Arm I vs 50% in Arm II ( p =0.04), but did not have any impact on overall survival OAS (5 years); 73% vs 77% ( p =0.79). Voice/laryngeal preservation was possible in 18/29 patients (62%) treated with RRT+/− Sx, without significantly affecting the OAS. ‘Pathological upstaging’ was another significant finding seen in 64% of clinical T3 after radical surgery. Conclusion: RRT+/−SSx can be a feasible option in low volume, favourable resectable stage III and IV supraglottic lesions for better quality of life.

Anorectal melanoma: a large clinicopathologic study from India.

Abstract: Anorectal melanoma is a rare tumor. It has dismal prognosis; only 10% of patients live longer than 5 years. It commonly presents as bleeding from the rectum or as a hemorrhoidal mass. The management of this tumor is controversial. Some authors believe that a palliative local excision is the treatment of choice, whereas others recommend radical surgery in localized disease. We present a retrospective analysis of 72 patients who were managed at our center between 1990 and 2001. This is the largest series from India. Most patients (48/72; 66%) presented with distant metastases. Twenty-four patients (24/72; 33%) underwent an abdomino-perineal resection. Nineteen patients (19/24) had positive lymph node disease, and the mean disease-free survival in these patients was 10.3 months. Disease-free survival in the node-negative patients was 26.5 months. A subset of patients with localized disease can benefit from radical surgery. In patients with large bulky localized disease, radical surgery provides better palliation than local excision.

Pancreatic tuberculosis: an elusive diagnosis.

Abstract: Background Pancreatic tuberculosis is a rare disease. Its presenting features are usually vague and non‐specific, while the radiological features mimic pancreatic malignancy in many cases and pancreatitis in others. Ultrasound‐ or CT‐guided fine‐needle aspiration cytology (FNAC) or biopsy may show caseating granulomatous inflammation but microbiological confirmation may not always be possible. Laparotomy may be required if other investigations prove inconclusive. The response to treatment is good. Case outlines We report two young men with pancreatic tuberculosis. The diagnosis was obtained by FNAC in one and laparotomy in the other. Each patient responded to anti‐tuberculous chemotherapy and is now asymptomatic. Conclusion Tuberculosis should be considered in the differential diagnosis of an obscure pancreatic mass, and the condition is readily curable.

Bile cultures and sensitivity patterns in malignant obstructive jaundice.

Abstract: BACKGROUND: Bactibilia is one of the important factors in the development of postoperative septic complications. We undertook this retrospective analysis to identify the organisms present in bile and their antibiotic susceptibility patterns in patients with malignant obstructive jaundice. METHODS: Bile specimens were obtained during endoscopic cholangiography (ERC; n=65), by flushing biliary stents (n=15), intra-operatively before incising the common bile duct (n=7) or during percutaneous transhepatic biliary drainage (PTBD; n=1). Eighty-eight samples from 65 consecutive patients were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant septic complications such as wound infection and cholangitis were also assessed. RESULTS: Of 65 patients (hilar block 39, distal block 26), 17 (26.1%) had bactibilia at initial ERCP; in addition, 3 of 7 bile specimens obtained during surgery, one collected during PTBD, and 13 of 15 stent flushings grew bacterial organisms. Cholangitis developed in 15 patients (12 with hilar block, 3 with distal block). Blood cultures were positive in 3 cases, and initial bile culture was positive in four patients with cholangitis. The most commonly found organisms were Escherichia coli (36.6%), Klebsiella pneumonia (18.3%), Pseudomonas aeruginosa (8.3%), Proteus vulgaris (8.3%) and coagulase-negative staphylococci (8.3%). The organisms found on ERC were similar to those found at wound cultures in 3 of the 4 cases who developed wound infection. Amikacin, gentamicin, cefotaxime, ceftazidime, and cefoperazone-sulbactam combination showed good activity against E. coli and K. pneumonia. CONCLUSION: Approximately one-fourth of patients with malignant obstructive jaundice have positive bile cultures at initial ERC. Post-ERC cholangitis is common in hilar blocks.

Primary ovarian lymphoma: report of cases and review of literature.

Abstract: Primary female reproductive system lymphomas are distinctly uncommon. We report two cases with primary ovarian non Hodgkin's lymphoma (NHL) having unilateral involvement in one case while the other had bilateral ovarian involvement. Both cases initially presented with ovarian enlargement. The median size of the tumour was 5.8 x 5 cm2. Histologically, by using the WHO classification, one lesion was classified as diffuse small B cell phenotype of intermediate grade and the other as diffuse high grade, B cell phenotype. On the basis of staging studies and clinical follow up, we conclude that both of the neoplasms in the report arose in the ovary. Both of the patients are disease free at 24 months and 6 months of follow up respectively, following excision and chemotherapy. We conclude that that the complete remission and failure free survival of patients with ovarian NHL treated with appropriate treatment appear to be similar to that of patients with extranodal NHL.

Leiomyosarcoma of the esophagus.

Abstract: Leiomyosarcomas of the esophagus are rare, malignant, smooth-muscle tumors. The presenting symptoms are indistinguishable from other esophageal neoplasms, though the history may be longer due to the slow growth of these tumors. Barium studies may show large intramural masses with ulceration or tracking, expansile intraluminal masses or areas of luminal narrowing. Endoscopic biopsies may give a high false negative rate especially in cases where the mucosa is intact. The treatment of choice is surgical excision. Synchronous and metachronous metastases do not preclude surgery, provided the metastases are also resectable. Prognosis is better than in patients with squamous esophageal cancer. The role of adjuvant radiotherapy and chemotherapy is controversial. We report a 40-year-old man who presented to us with dysphagia and was found to have a leiomyosarcoma of the esophagus. He was treated successfully with esophagectomy and is disease-free after 7 years. We review the literature on esophageal leiomyosarcomas and their management.

Use of irradiated amnion as a biological dressing in the treatment of radiation induced ulcers.

Abstract: The management of moist skin desquamation (ulceration) following radiation therapy has been a concern since the inception of this therapy. The treatment of skin reactions focuses on promoting healing, improving patient comfort preventing infection and decreasing trauma to the area. Various dressings like topical preparations, hydrocolloid and gentian violet 1 % dressing have been used for its treatment. We present our experience with the use of amnion as a biological dressing in patients with radiation induced ulceration following pelvic radiation using megavoltage beam. The preliminary experience with treatment in 14 patients proved to be cost effective due to a shorter duration of ulcer healing (median of 7 days), fewer dressing changes (median of 4 dressings) and diminished use of analgesics.

Aberrant subclavian artery causing difficulty in transhiatal esophageal dissection

Abstract: The right subclavian artery normally arises from the brachiocephalic artery. Anomalies in development may lead to peculiar problems during surgery. We report a patient with esophageal carcinoma who had an aberrant right subclavian artery, posing specific difficulties during a transhiatal esophagectomy, requiring conversion of the procedure into a transthoracic approach. The embryologic basis of this anomaly and the clinical significance are discussed.

Re: Doussis-Anagnostopoulou et al. Vascular endothelial growth factor (VEGF) is expressed by neoplastic Hodgkin-Reed-Sternberg cells in Hodgkin's disease. J Pathol 2002; 197: 677-683.

Abstract: We find the article by Doussis-Anagnostopoulou et al on vascular endothelial growth factor (VEGF) expression in the Reed-Sternberg (RS) cell in Hodgkin’s disease (HD) interesting [1]. As in other tumours, the authors suggest that VEGF expression promotes neoangiogenesis and this in turn promotes tumour growth. The hypothesis is that the VEGF secreted by RS cells provides mitotic, growth, and differentiation signals to endothelial cells; this essentially implies a paracrine pattern of growth stimulation in the endothelial cells. However, the inability of the authors to demonstrate a statistically significant correlation with microvessel density weakens the hypothesis, although dependence of RS cells on neoangiogenesis cannot be negated. We were interested in exploring the possibility that there is aberrant expression of VEGF receptors — VEGFR-1 (Flt-1) and VEGFR-2 (KDR/Flk1) — in RS cells and whether this combination of expression of VEGF and their receptors could indeed provide an autocrine pathway of growth stimulation in RS cells. We studied the expression of VEGF and its receptors VEGFR-1 and VEGFR-2 by immunohistochemistry in ten cases of HD. Immunohistochemistry was carried out with mouse monoclonal antibodies Santa Cruz, CA, USA) on 4-μm thick paraffin sections of cases of HD — mixed cellularity subtype. An avidin–biotin–peroxidase method without any signal amplification was used. VEGF expression in the RS cells was seen both as a diffuse cytoplasmic and as a paranuclear (Golgi staining) signal. In addition to the RS cells, plasma cells, histiocytes, and fibroblasts also expressed VEGF. Among the RS cells that expressed VEGFR-1/VEGFR-2, the staining was seen in the cytoplasm and on the membrane. Expression of VEGFRs was also noted in the endothelial cells, plasma cells, and histiocytes. Cases were analysed for the percentage of positive RS cells. Expression in less than 10% of RS cells was considered negative. In a majority of cases, we found co-expression of VEGF and VEGFR-2 (Figure 1 and Table 1). Conventionally, angiogenic molecules have been thought to act on endothelial cells and promote mitosis and permeability. The expression of VEGFRs was initially thought to be predominantly restricted to endothelial cells and the downstream events were also thought to be cell type-specific [2–4]. Furthermore, among VEGFRs, VEGFR-2 is primarily thought to mediate the growth and permeability signal, A

Thoracic duct cyst of the mediastinum.

Abstract: Thoracic duct cysts of the mediastinum are extremely rare. The etiology may be related to a congenital or degenerative weakness in the wall of the thoracic duct. They are generally asymptomatic but may sometimes cause pressure effects on adjacent structures. Imaging studies are supportive but not diagnostic. Excision of these cysts is required for diagnosis and to prevent complications. We describe a 49-year old man who presented to us with hoarseness and a fixed right vocal cord. Computed tomography (CT) showed a cystic posterior mediastinal mass in the right paratracheal region. We performed a posterolateral thoracotomy and found the cyst arising from the thoracic duct and contained chylous fluid with a high lipid concentration. We dissected the cyst from the surrounding structures and excised it. Histopathology revealed a cyst lined by a single layer of endothelial cells. He is asymptomatic now one year after surgery.