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Intracranial atypical teratoid rhabdoid tumor is an uncommon malignancy with a dismal outcome. Commonly misdiagnosed over the decades as primitive neuroectodermal tumor of the brain, it has dramatically different biological behavior. We herein report a case series of five patients diagnosed and treated as atypical teratoid rhabdoid tumor of the brain in a major cancer center in north India. We have also analyzed the clinical, histopathological, and radiological features and the therapeutic options of this enigmatic tumor.

Visual optimization is a very interesting topic to the application users for many purposes. It enables the user with an interactive platform where, by varying different parameter settings, one can customize a solution. Several attempts of developing generalized evolutionary optimizers are found in literature which work well for function optimization problems only. Solving combinatorial optimization problems on such a general platform is a difficult task. In this paper, we have tried to solve partitional clustering problem using a generalized visual stochastic optimization algorithm that was initially developed for function optimization problems only.

This work introduces coupled Cellular Automata (CA) and LFSR (CA-LFSR) machine, defined in Galois Extension Field (GF(2p)), for the cost optimal design of 3-D steel building frames. Tall steel building frames are subjected to substantially high lateral forces due to wind and/or earthquake, in addition to the usual dead and live loads. The cost of construction of such frames can be reduced by providing additional structural steel members, called bracings, between suitable pairs of nodes of the building. The patterns generated from a CA-LFSR, tuned to the structural configuration of a building, dictates the desired positions of bracings resulting in a structure with reduced construction cost. The cost optimal design developed around the CA-LFSR is reached in constant time that is possible with the conventional design procedure based on the principles of structural engineering. Exhaustive experimentation establish that the proposed CA-LFSR based approach is most effective for the design of tall building frames, and can reuse a design for scalability.

The hepatitis B virus (HBV) is estimated to have infected about 350 million people worldwide, making it one of the most common human pathogens. Renal involvement is among its most common extra hepatic manifestations and usually manifests in the form of immune complex mediated glomerulopathy, such as membranous glomerulonephritis (MGN), membranoproliferative glomerulonephritis (MPGN), mesangioproliferative glomerulonephritis and immunoglobulin A (IgA) nephropathy. Occurrence of focal and segmental glomerular sclerosis (FSGS) with HBV infection is rare and only five cases have been reported earlier. We report two cases of hepatitis B associated FSGS. In both the cases, HBsAg was demonstrated in the renal tissue and both the cases showed response to treatment with lamivudine, thus indicating a possible causal association between the viral infection and occurrence of nephrotic syndrome.

Colorectal carcinoma (CRC) is rare in the Indian subcontinent. The two-hit carcinogenic theory has been well established from the turn of this century, in which p53 is described as a late marker in colorectal carcinogenesis, and murine double minute 2 (mdm2) has not yet been correlated with colorectal carcinoma. With the recent introduction of anti-mdm2 oligonucleotides, it is apparent that if its role can be established in colorectal carcinogenesis, the DNA conservation of the wild p53 strain would be achieved therapeutically because mdm2 conserves the wild p53 strain. We studied 32 cases with adequate number of controls and found a positive correlation ( P = .001) between these proteins. These proteins were expressed in tumor adjacent to the hyperplastic mucosa, dysplastic mucosa, and aberrant crypt foci, unlike in studies in the West. The expression of these proteins was correlated with aggressive tumor behavior. All these indicate significant diagnostic, therapeutic, and prognostic roles for these proteins.

Signet-ring cell type of gastric carcinoma can easily escape detection by the pathologist, and this confusion is compounded by the presence of morphologic patterns other than the conventional appearance. One such morphologic variant is composed of deeply eosinophilic cells containing minute cytoplasmic granules with neutral mucin. With this morphology, epithelioid gastrointestinal stromal tumor (GIST), and hepatoid and rhabdoid variants of adenocarcinoma enter the list of diagnostic possibilities, and accurate diagnosis is essential for therapeutic and prognostic considerations. We report a 28-year-old man who presented with dyspepsia, nausea, vomiting, and black-colored stools. Endoscopy revealed a growth at the incisura, a biopsy specimen from which was reported as a poorly differentiated tumor. The patient underwent subtotal gastrectomy and the resected specimen showed a 6.5 × 4-cm circumferential growth in the antropyloric region. Histological sections from the growth showed transmural infiltration by deeply eosinophilic cells with hyperchromatic nuclei. A differential diagnosis of epithelioid GIST, rhabdoid variant, hepatoid variant, and signet-ring cell adenocarcinoma was considered. Special stains and immunohistochemistry confirmed the tumor to be a variant of signet-ring cell adenocarcinoma of the stomach. Morphologic variations of signet-ring cell carcinoma pose an important diagnostic dilemma, which has therapeutic and prognostic significance for the patient. These variants need to be recognized by pathologists to enable an accurate diagnosis.

Background Fulminant hepatic failure (FHF) is rapidly fatal and liver transplant is the treatment of choice. The condition is known for its heterogeneity of defining criteria, clinical presentation, histologic spectrum and etiologic factors. The etiology of FHF varies widely, some of which includes viral hepatitis, drug overdose and idiosyncratic drug reactions. The identification of the etiology of FHF is critically important, because it influences the management. A histopathological classification of FHF has not been reported earlier in the literature. Methods The current study was conducted retrospectively on 224 autopsies at a tertiary care hospital in India. In all of these cases the liver was examined grossly and microscopically. Clinical findings, serological data and immunohistochemical findings were correlated with the morphological subtypes and a consensus morphological classification was formulated. Results Young females, especially those in the reproductive age group were most susceptible to the disease. Hepatotropic viruses and drugs were the likely causes in most of the patients. Clinical presentation is important, as delayed onset of encephalopathy or the subacute FHFs lead to maximum mortality. After careful gross and microscopic examination the morphological findings of FHF were divided into four distinct categories. Histologic typing can sometimes be misleading if solely made on H & E slides without application of special stains. Conclusion Fulminant hepatic failure is a medical emergency, proper histological categorization can help in deciding the treatment modalities.

Background The presence of aberrant crypt foci (ACF) represents an important preneoplastic condition of the large intestine. The ACF are used extensively as the biological end point to study the effects of diet, biological agents and chemotherapeutic agents as they undergo distinct morphological and genetic changes in response to these factors. Till date, in human ACF, K-ras, beta-catenin, carcinoembryonic antigen (CEA) and adenomatous polyposis coli (APC) protein expression have been investigated, but the expression of late markers of colon carcinogenesis have not been studied in great detail. Aims To study the significance of ACF in carcinogenesis, the incidence of ACF in colorectal carcinoma (CRC) patients and the expression profiles of the tumor repressor protein p53 and the murine double minute (mdm2) protein in ACF. Methods and materials The pattern of expression, histology and immunohistochemistry of the p53 and mdm2 proteins were studied in 32 colectomy specimens. Careful scoring was carried out using standard criteria. The prevalence of ACF, types of ACF, surrounding mucosal changes and the relation of ACF with tumor morphology and aggressiveness were determined, as was any difference in the staining pattern between hyperplastic and dysplastic ACF. Result Aberrant crypt foci were present in a large number of cases (84.4%), of which 65% were hyperplastic. All hyperplastic and dysplastic ACF tested positive for p53 in the nucleus. Both the nucleus and cytoplasm tested positive for mdm2 irrespective of the degree of dysplasia. No correlation was noted between ACF and tumor histology. Conclusion The p53 and mdm2 proteins are expressed during the very early stages of mucosal changes in ACF, irrespective of histological changes, but the pattern of expression can differ depending on geographical barriers, genetic factors, diet and environmental conditions. This results suggests that the conventional adenoma–carcinoma sequence is not completely correct. The detection of ACF and p53 and mdm2 expression can help to curtail the disease in its early stage by targeted therapy.

Adenoid cystic carcinoma (ACC) of breast is a fairly uncommon malignancy, accounting for 0.1% of all cases of breast carcinomas. Though ductal or lobular breast carcinomas can be multifocal/multicentric examples of the multifocal breast ACC is sparse. Hereby we report a case of retro-areolar multifocal ACC of the breast in a 36 year old female with typical grade 1 histomorphology. Characterization is important as ACC breast has an excellent prognosis with little chance of lymph node and distant metastases. However, our case metastasized after undergoing wide local excision. This example reminds both the physician and pathologist to consider ACC in the differential diagnosis of retroareolar multicentric/multifocal breast carcinoma and the importance of mastectomy with axillary clearance in all histological grades. The Sri Lanka Journal of Surgery 2015; 33(3): 18-19

There are currently two major schools of thought or theories that explain the formation of tumours. According to the classical stochastic theory or clonal-evolution model of carcinogenesis, it is believed that a cancer cell develops as a random process (stoʊˈkaestɪk in Greek, means “guessing” indicating randomness) and thus any cell in the body can undergo the required harmful changes in DNA sequences that culminate in the formation of cancer1. Eventually there is a clonal-selection of cells such that a clonal population of cells forms the cancer. The other model is the cancer stem cell (CSC) or tumour initiating cell (TIC) theory. The cancer stem cells model proposes that tumours are made of a heterogenous cells comprising a small population of cancer stem cells and a bulk of non-cancer stem cells. These cancer stem cells have properties of self-renewal and differentiation. In this model of cancer biology, the presence of residual CSC gives rise to tumour relapse1,2,3. This is also true for the local intra-organ or distant metastasis, where the CSC in tumour emboli may act as a hidden reservoir of cancer cells and give rise to distant relapse and metastasis1,2. Since these cells posses distinct charecteristics and comprise a very small percentage (1-3%) of the total tumour burden1,2 and drive tumour development and tumour sustenance, it is logical to believe that identification and subsequent targeted therapy would go a long way in treating malignancies3.

We study domain kinetics in ferroelectric films, subsequent to a rapid quench below the critical temperature. We model the kinetics via the time-dependent Ginzburg-Landau (TDGL) equation for the Ginzburg-Landau-Devonshire (GLD) free energy, which is a functional of the electric polarization vector . The nature of ordering dynamics depends on the strength of coupling between Px and Py. For , domain growth is mediated by the annihilation of vortex defects with the growth law . For , the corresponding defects are sharp interfaces between four-fold-degenerate ground states. The resultant growth law is purely diffusive: .

Temozolomide (TMZ) is an oral alkylating agent with significant activity against glioblastoma multiforme (GBM) and melanoma. It increases survival by 2.5 months when used in combination with radiotherapy as an adjuvant therapy in GBM. Secondary MDS/AML or non-Hodgkin lymphoma attributed to TMZ exposure has been reported. We report a case of non-Hodgkin lymphoma secondary to temozolomide in a 20-year-old female who was treated for GBM with concurrent TMZ and radiotherapy. She developed lymphoma 2 months after completing chemoradiotherapy. Although she was treated with combination chemotherapy for lymphoma, she died of progressive GBM.

e19524 Background: Follicular lymphoma (FL) is second most common lymphoma in adult, constituted 20% of all lymphoma cases in the west. There is limited information is available on FL from India. Methods: The clinic-pathological profile, treatment outcome and prognostic factors for survival were assessed in 181 patients of FL seen at AIIMS, New Delhi, a large tertiary referral centre, over a period of 17 years (1996-2012). Results: There were 120 males and 61 females. The median age was 51 years (24-80 years). The common presenting features were lymphadenopathy 71%, fatigue 23% and fever 20%. Ann Arbor Rai stage distribution was: stage I - 9%, stage II - 11%, stage III -22 % and stage IV - 58%. Thirty six patients (20%) had ECOG performance status III/IV. Extra nodal involvement and bulky disease were present in 40 (22%) and 31 (19%) patients respectively. Follicular Lymphoma International Prognostic Index (FLIPI) 1 score : Low -25%, Intermediate-45% and high risk in 30% of cases. FL grade 1, 2 and 3 were seen in 63 ( 35%), 63 (35%) and 55 (30%) patients respectively. One forty five patients (80%) received treatment at presentation. Chemotherapeutic regimen used were: CHOP-45 , CVP-51, chlorambuil and prednisolone -7 , BR ( bendamustine and rituximab)-12, RCHOP- 14 and RCVP in 7 cases. The overall response (ORR) and complete remission (CR) rates were 70% and 35% respectively. Relapse occurred in 54 patients, 50 patients died and progression was observed in 63(35%) patients. Median overall survival (OS) and event free survival (EFS) was 5.5 years and 3.5 years respectively, with median follow up period of 3 years. Grade 3 histology, failure to attain CR, low serum albumin, PS III/IV, bulky disease and high risk FLIPI were significantly associated with lower event free survival. High risk FLIPI (HR 1.46, 95% CI 1.03-2.10, p=0.003) and failure to attain CR (HR 2.64, CI 1.10-4.30, p=0.001) were predictors of poor OS. Conclusions: FL represents 9 % of all lymphoma in adult. This is the largest data from single institute from India. Eighty percentage of patients presented in stage III/IV disease. High risk FLIPI and failure to attain CR were important prognostic variables for OS.

findings strongly suggest that GPR30 is a novel, selective target for the prevention and the treatment of estrogen-induced cholesterol gallstones. Conclusions: GPR30 is also involved in estrogen-dependent lithogenic actions, working independently from ERα, as both GPR30 and ERα can work through different pathways to promote the formation of estrogen-induced gallstones. Distinguishing the lithogenic actions of GPR30 from ERα and further investigating how estrogen produces lithogenic actions via GPR30 may help better understand the molecular mechanisms behind the formation of cholesterol gallstones induced by estrogen.

Glassy cell carcinoma (GCC) is a rare clinical entity involving uterine cervix with aggressive course and relatively poor prognosis. The most common presentation is abnormal bleeding or discharge per vaginum of recent origin. Histologically it is diagnosed by characteristic "Glassy" cells. All the three modalities (i.e. surgery, radiotherapy and chemotherapy) have been tried in various clinical settings, showing different clinical outcome. The common consensus regarding diagnosis and optimal treatment modalities is yet to emerge. The case presented here not only represents a rare histopathological diagnosis, but also reemphasizes the importance of Her2 neu immunostains as a bad prognostic marker. Key words: glassy cell carcinoma; radiotherapy; Her2 neu; cervix. DOI: http://dx.doi.org/10.4038/sljog.v33i2.4010 Sri Lanka Journal of Obstetrics and Gynaecology 2011; 33 : 65-67

About two billion people worldwide have been infected with the hepatitis B virus and about 350 million live with chronic infection. Besides, an estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B. The course of HBV infection is a dynamic process and is influenced by many factors including viral, host, and exogenous factors. Clinical suspicion of acute viral hepatitis usually does not necessitate biopsy; however, persistence of clinical symptoms or biochemical evidence of hepatotrophic viral infection for more than six months duration necessitates a liver biopsy - in several instances to primarily establish the histopathological diagnosis, to grade and stage the hepatic changes (determine management and prognosis), to document the severity and extent of the hepatic inflammation, as a guide to therapy or to monitor the changes of liver histology while on treatment. Moreover, improvement in liver histology can be used as an endpoint in clinical trials for new forms of therapy. Additionally, in some cases there is considerable clinical overlap between the states of exacerbation of chronic hepatitis and acute hepatitis. Biopsy is helpful in these cases too. Nevertheless, it must be mentioned that with the current trends and various guidelines, the indications for liver biopsy in chronic hepatitis B are somewhat reduced. It is hoped that with non-invasive markers the number of liver biopsies will reduce further. This article provides an overview of the histopathology of chronic hepatitis B virus infection.

Primary focal segmental glomerulosclerosis (FSGS) has recently been divided into five subtypes by the Columbia classification. However, little is known about the incidence of these subtypes in the Indian population. In addition, there are very few studies evaluating the clinico-pathologic features with morphometric parameters in these subtypes. This study was aimed at evaluating the clinical, histopathological and morphometric parameters in various subtypes of FSGS at our referral center. Sixty-five (65) cases of idiopathic FSGS, diagnosed over two years (2006-2007), were included in the study. Detailed clinical and biochemical investigations were noted. Histological sections were reviewed and cases classified according to the Columbia classification and various glomerular and tubulo-interstitial features were noted. Glomerular morphometry on digitized images was performed using image analysis software. Renal biopsies with minimal change disease were used as controls for morphometric evaluation. In this study, FSGS not otherwise specified (NOS) was the most common subtype (44.6%), followed by perihilar FSGS (24.6%), collapsing (13.8%), tip (12.3%) and cellular FSGS (4.6%). Collapsing subtype showed significantly shorter duration of symptoms and higher degree of proteinuria, mean serum urea and creatinine compared with the other subtypes. On histologic analysis, features like glomerular hyalinosis, capsular adhesion, mesangial proliferation and visceral epithelial cell prominence (VEP) were frequently seen. The cases with VEP had a shorter duration of symptoms and a higher mean serum creatinine and 24-h urine protein excretion compared with those without VEP. The morphometric study revealed a significant higher mean glomerular area in the NOS, perihilar and collapsing variants as compared with the control biopsies. The present study highlights the differences in the prevalence in the FSGS subtypes in our population compared with the western data. Also, the significant differences in the clinical, biochemical and histological parameters reaffirm the utility of the Columbia classification of FSGS in routine reporting of renal biopsies. We found VEP (without causing collapse of the tuft) to be associated with higher serum creatinine at presentation. This feature needs to be evaluated in further studies for its potential significance.

Granulocytic sarcoma (GS) usually presents concomitantly with or after the onset of acute myeloid leukemia, blastic phase of chronic myeloid leukemia (CML), or myelodysplastic syndromes. Rarely, it may present even before the onset of overt leukemia and when so, it is often misdiagnosed. We are reporting a case of GS of kidney presenting as an isolated renal mass with normal laboratory investigations including a normal peripheral blood smear. It was initially misdiagnosed as lymphoma as the blasts, in addition to the morphological similarity with lymphoma cells, also showed positive immunohistochemistry for B cell markers. Based on further investigations including immunophenotyping and cytogenetic studies, a final diagnosis of CML-blast crisis (mixed phenotype) presenting initially as GS was made. To the best of our knowledge, this is the first antemortem report of nonleukemic GS presenting as kidney mass that later on progressed to CML-blast crisis with mixed phenotype blasts.

A 55-year-old male with carcinoma in situ of urinary bladder was treated with weekly intravesical injections of Bacillus Calmette Guerin (BCG) vaccine. Three days after the sixth injection, he developed low grade fever and multiple grouped punched out, 2-3 mm ulcers around meatus and corona glandis. In addition, multiple, firm, indurated, nontender papules and few deeper nodules were present on the proximal part of glans penis, along with bilateral enlarged, matted and nontender inguinal lymph nodes. There was no history suggestive of sexually transmitted diseases and high risk behavior. Chest X-ray was within normal limits, and Mantoux, Venereal Disease Research Laboratory (VDRL) and HIV antibody tests were negative. The biopsy from the penile ulcer revealed epithelioid cell granuloma with Langhans giant cells. Fine needle aspiration cytology from the lymph node also revealed epithelioid cell granuloma and acid fast bacilli on Ziehl Neelsen's stain. The tissue biopsy grew Mycobacterium tuberculosis. The BCG immunotherapy was stopped and patient was treated with four drug antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide in standard daily doses along with pyridoxine. The edema resolved and the ulcers started healing within 2 weeks, and at 6 weeks after starting antitubercular therapy almost complete healing occurred. To the best of our knowledge, we describe the first case of an Indian patient with BCG induced primary tuberculosis of penis after immunotherapy for carcinoma urinary bladder and review the previously described cases to increase awareness of this condition in dermatologists and venereologists.

Objectives The purposes of this study were to elucidate the histomorphometry of the intrapulmonary arteries in patients undergoing univentricular type of repairs and to identify the histomorphometric characteristics, if any, that may predispose patients to postoperative Fontan failure. Patients and methods Operatively resected wedges of lung tissue from 44 patients undergoing univentricular type of repairs (aged 17 months to 34 years; mean, 83.52 ± 75.90 months) was subjected to histomorphometric analysis. Results Despite pulmonary arterioplasty, a low Nakata index was associated with 9.61 (95% confidence interval: 1.01–91.5; P = .003) times increased risk of death after the operation. A statistically significant difference in the mean indexed diameter of the intra-acinar pulmonary arteries ( P = .03) was observed between patients undergoing superior and total cavopulmonary connections. Overall, there were 8 (8.2%), 4 (9.1%), 13 (29.5%), and 29 (65.9%) instances of intrapulmonary arterial intimal lesions, thrombosis, smooth muscle extension, and interstitial fibrosis, respectively. Among patients undergoing total cavopulmonary connection, only low Nakata index was significantly associated with the presence of severe intimal lesions, abnormal smooth muscle extension, intra-acinar pulmonary arterial thrombus, and smaller intra-acinar pulmonary arteries. Conclusions A low Nakata index is significantly associated with the presence of severe intimal lesions, thrombus, abnormal smooth muscle extension, a lower mean indexed area of the intrapulmonary arteries, and poor postoperative outcome. However, none of the histomorphometrically derived parameters could conclusively predict the outcome after univentricular repair.

e18549 Background: The largest series on peripheral T-cell lymphoma (PTCL) [International T-cell Lymphoma project] reports the incidence of PTCL (4-21%) from various regions of the world. However, ...

Intracranial hemangiopericytomas are rare tumors with aggressive behavior. Other than the meninges, this lesion has rarely been reported in periventricular and sellar region. We report a case of malignant hemangiopericytoma in sellar region in a 47-year-old male who presented with history of sudden onset of bilateral visual disturbances. To best of our knowledge, this is the second case report of malignant hemangiopericytoma in this location. As this intracranial lesion shows aggressive behavior, in the form of recurrence or extracranial metastasis in comparison to its extracranial counterparts, diagnosis should be made cautiously.

Introduction: Human papilloma virus (HPV) is a causative factor in the genesis of cervical cancer. Curcumin can act as an adjuvant in cancer therapy with essentially no side effects. In this study, we elucidated the role of curcumin as an adjuvant to chemo and radiotherapy in patients suffering from cervical cancer. Experimental Design: This was a pilot study of a Phase III, randomized control, double blind clinical trial. Forty five histopathologically confirmed patients of cervical cancer (stage IIb to IIIb) were enrolled. The patients were randomized into Group A/Group B and given curcumin (4gm/day for 3 months)/placebo along with chemo and radiotherapy. Cervical scrapes / pap smears were collected at baseline, 1 month (1st follow up) and 6 months (2nd follow up) post treatment. HPV status, viral load, PCNA and P16INK4A protein expression were investigated. CT scan was done at 6 months to see the final outcome of treatment. Results: A significant drop in the viral load post treatment was seen in both groups but not between the groups. A non significant decrease in PCNA was seen at 1st follow up which increased at 2nd follow up in both the groups. Increased P16INK4A expression was seen at 1st follow up that decreased at 2nd follow up, similarly in both groups, but was not significant. No significant difference in outcome between both the groups was observed at 6 months post treatment. Conclusion: Group A patients received curcumin and Group B received placebo. This is the first clinical trial with curcumin in advanced cases of cervical cancer. Curcumin was well tolerated. No significant difference was found between the two groups which could be due to the small sample size or short duration of follow up. No correlation was found between HPV viral load, PCNA and P16INK4A protein expression. Citation Information: Cancer Prev Res 2010;3(1 Suppl):A82.

e14580 Background: Survival of patients with advanced epithelial ovarian cancer (EOC) with initial suboptimal debulking surgery (residual disease (>1 cm) and those with recurrent EOC is poor. We used EGFR inhibitor gefitinib for maintenance and analyzed data on safety and toxicity. Methods: Between Nov. 2004 and Dec. 2008, Patients who achieved complete response (CR) following six cycles of paclitaxel and carboplatin received gefitinib as (Group I). Similarly, patients with recurrent EOC who achieved CR following six cycles of salvage CT received gefitinib (Group II). Both groups received gefitinib 250 mg once daily till evidence of relapse. Patients were examined every month and toxicity (CTC version II) was recorded. Serum CA-125 was done once in 2 months and CAT scan of abdomen & pelvis every 6 month. The study was approved by Institute Ethics Committee and informed written consent was obtained from each patient. Results: A total of 48 patients (median age 47 years, range 23 to 63) have been recruited. Group I: 17 subjects and Group II 31 patients (1st relapse- 13, 2nd- 9, 3rd -6 & 4th relapse in 3 patients). The mean duration of gefitinib treatment is 8.77 months (Gp-I: 14.4 months, Gp-II: 5.68 months). Toxicity was mainly in the form of skin rash & diarrhea. Skin rash: 16 patients (33.3%); Group I - 8 (grade I-2, II-4, III-3,) & Group II - 8 patients (grade I-3,II-4,III-1). Diarrhea: 12 patients (25%); Group I-3, group II- 9) all grade I. Two patients had both skin rashes and diarrhea. No pulmonary or hematological toxicity was observed. Currently, 13 patients are on gefitinib (mean duration of treatment 12.6 months); in 34 patients gefitinib has been discontinued due to relapse and in 1 patient due to grade III skin rashes over face. Among 18 patients with skin toxicity, 8 continue to be disease-free compared to 6 of 30 without skin toxicity (p=0.07). Conclusions: Gefitinib was tolerated well with mild toxicities limited to skin and GIT. Correlations between EGFR expressions vs. response may help to identify patients likely to benefit from gefitinib therapy. No significant financial relationships to disclose.

A 40-year-old male paddy field worker was referred for exertional shortness of breath and non-productive cough for 4 years. He had been treated for pulmonary tuberculosis twice. Chest radiograph showed extensive bilateral nodular opacities ("sandstorm-like") in the middle and lower lobe. Pulmonary function tests revealed a restrictive ventilatory defect. High resolution CT showed widespread nodular infiltration with "crazy paving" appearance and interrupted black pleura sign. This was confirmed as pulmonary alveolar microlithiasis (PAM) by trans-bronchial lung biopsy, which showed normal respiratory lining epithelium with dilated alveolar spaces containing many calcific bodies, some of which showed concentric calcification. The possibilities of silicosis (due to exposure to husk) and tuberculosis, both of which can mimic PAM clinically and radiologically, made this case a diagnostic challenge.

Primary hepatic lymphoma (PHL) is a lymphoproliferative disorder confined to the liver without evidence of involvement of spleen, lymph nodes, bone marrow or other lymphoid structures. This is in contrast to Non Hodgkin's Lymphoma (NHL) that often involves the liver as a secondary manifestation. PHL is a rare disease and constitutes 0.016% of all cases of NHL. PHL typically occurs in middle aged men, and usually the chief presenting symptoms are non specific which includes right upper quadrant pain, B symptoms like fever and weight loss and constitutional symptoms. Most frequent physical finding is hepatomegaly which occurs in 75% of patients. Jaundice is rare and present only in less than 5% of patients. Majority of PHL originates from B cells. The blood investigations and imaging findings are nonspecific. Histopathology is essential and confirms the diagnosis. Treatment modalities include combination of surgical resection, chemotherapy and radiotherapy. The prognosis without therapy is grim. The prognosis and management of PHL is different from hepatocellular carcinoma or metastatic disease, hence it is essential to differentiate it from these diseases. The purpose of this review is to emphasize the importance of accurate diagnosis before implementing therapeutic plan for any hepatic space occupying lesion in liver.

Introduction Therapy related second malignancy of the hematological system is small but real risk after adjuvant chemotherapy for breast cancer. It includes acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS); however T-cell prolymphocytic leukemia (T-PLL) has not been described earlier in relation to breast cancer and its therapy. T-PLL is a rare chronic T-cell lymphoproliferative disease with a mature post-thymic T-cell immunophenotype and aggressive clinical course. Case presentation A 45 year old Indian female of Nordic origin presented 5 years back with a lump in the right breast and the axilla. She underwent modified radical mastectomy. Histophotomicrograph of the excised breast lesion showed a 2.1 cm duct carcinoma, positive for ER and PR with 1 out of 25 lymph nodes positive for metastasis. She received 6 cycles of chemotherapy with cyclophosphamide, epirubicin, and 5-fluorouracil. This was followed by tamoxifen 20 mg per day for five years. She was doing well on follow up until the completion of fifth year of her disease, when she presented with complaints of mild fever and weakness. Examination revealed generalized lymph node enlargement along with hepatomegaly. Hemogram showed mild anemia, normal platelet count and a leukocyte count of 1.2 × 1011/L. Peripheral blood examination revealed medium sized lymphoid cells, constituting almost 75% of total nucleated cell population. Immunophenotying, established a diagnosis of post thymic T-cell prolymphocytic leukemia. Contrast-enhanced computed tomography of the chest and abdomen was done which revealed an anterior mediastinal mass with destruction of sternum along with multiple small nodular shadows in bilateral lung fields suggestive of lung metastasis. Fine needle aspiration cytology of the mass showed atypical ductal cells with nuclear pleomorphism, which were positive for ER, PR and Her2neu protein. This confirmed a co-existent metastatic breast carcinoma. She was started on chemotherapy for T-PLL along with hormonal therapy with aromatase inhibitor. Unfortunately, both her malignancies progressed after an initial stable disease of two months. Conclusion Our case describes the potential of breast chemotherapy to cause grave second hematological malignancies of the T-cell lymphoid lineage, not described earlier. Such events highlight the importance to identify those patients of breast cancer in whom chemotherapy can safely be avoided.