An update in the management of malignant pleural effusion

Malignant pleural effusion (MPE) usually presents in the disseminated and advanced stage of malignancy. Dyspnea is the debilitating symptom which needs palliation in these patients. Various modalities are available in the management of MPE. Careful consideration of the patient's expected survival and quality of life is needed when deciding the optimum treatment modality in such patients. In this article, different modalities of the palliative management of MPE are discussed with an attempt to derive a treatment algorithm for the management of MPE.     

TP53 polymorphisms in gliomas from Indian patients: Study of codon 72 genotype, rs1642785, rs1800370 and 16 base pair insertion in intron-3

Several single nucleotide polymorphisms of the TP53 gene have been reported, amongst which polymorphism in codon 72 (rs1042522) has received significant attention and shown to be associated with disease susceptibility in different cancer types. However, there are variable reports on this polymorphism in gliomas from worldwide with inconsistent results. In addition, the implications of other polymorphic loci are not much explored in gliomas. Hence, in the present study the TP53 sequence was analyzed for all polymorphism and mutations in a total of 84 gliomas of different types and grades from patients of Indian origin. The complete sequence of all coding exons (2 to 11) and introns 2, 3, 5 and 8 of TP53 gene were studied while for introns 1, 4, 6, 7, 9 and 10, only exon flanking regions could be studied. The polymorphic loci were compared with control population. In addition to the well known codon 72 polymorphism (rs1042522), three other polymorphisms rs1642785, rs1800370 and a 16 base pair insertion in intron-3 were found. At codon 72, our study showed higher Arg/Arg genotype in gliomas compared to normal population (38% versus 13%). The Arg allele frequency in glioma patients was comparatively higher than controls (0.55 versus 0.45; P = 0.037). The Arg allele frequency was also high in adult glioblastomas compared to paediatric counterparts (0.55 versus 0.36). However, there was no significant association of TP53 mutations with any genotype of codon 72. At rs1642785, the G allele frequency was significantly higher in gliomas than in control population (0.55 versus 0.36, P = 0.005). The genotype at a 16 base pair insertion in intron-3 was almost similar in case and control. However, the polymorphism at rs1800370 was exclusive to gliomas. This is the first report of TP53 gene polymorphism in glioma patients from India. Our study also delineates the frequency of four polymorphisms in gliomas for the first time. The codon 72 variant (rs1042522) and rs1642785 polymorphisms possibly poses risk to glioma development in Indian population. However, the functional significance of these polymorphism needs further elucidation.     

Medulloblastomas: a correlative study of MIB-1 proliferation index along with expression of c-Myc,ERBB2, and anti-apoptotic proteins along with histological typing and clinical outcome

Background  Medulloblastoma (MB) is the most common pediatric brain tumor. It is however rare in adults. The genetic and protein expression profile of medulloblastoma is complex, which is worthwhile in terms of prognostication and development or selection of targeted therapy. Aims and objectives  The aims and objectives to correlate the MIB-1 proliferation index and protein expression profiles of c-Myc, ERBB2, and anti-apoptotic proteins (Bcl2 and Bcl-xL) in tumor cells with histological subtypes and clinical outcome. Methods and material  In 50 cases, histopathological subtyping was done, and protein expression profiling by immunohistochemical technique was performed by stains for MIB-1, Bcl2, Bcl-xL, c-Myc, and ERBB2 in 30 cases. The findings were correlated with histological types and patient’s average follow-up data. Results  Histological subtypes were similar to that described in literatures. The average expression of Bcl2, Bcl-xL, MIB-1, c-Myc, and ERBB2 were as follows: 50.38%, 38.18%, 59.03%, 46.16%, and 59.62%, respectively. Bcl2 expression showed statistically significant correlation with progress-free survival (PFS) [p = 0.046], while ERBB2 and MIB-1 showed a trend of higher expression in progressive disease. The protein expression pattern did not correlate with histological subtypes. Conclusion  Though Bcl-2, ERBB2, and MIB-1 LI came out to be potential markers of aggressive behavior, c-Myc did not correlate with PFS in MB.     

Insulin sensitivity as a risk factor for common carotid intima media thickness (IMT): its relation to atherosclerosis

INTRODUCTION: The relationship between insulin resistance and atherosclerosis (ATH) in non-diabetic hypertensive patients from the Asian Indian population remains poorly understood. To resolve this issue, the present study was designed to analyze whether insulin sensitivity in a non-diabetic individual is related to the development of ATH.(by using IMT as an index) and whether this relationship is dependent on the presence of other cardiovascular disease (CVD) risk factors such as dyslipidemia and hypertension. METHODOLOGY: This study included 68 healthy controls with no diabetes and hypertension and 41 hypertensive patients who underwent four-point oral glucose tolerance test (OGTT) and intravenous glucose tolerance test (IVGTT). A biochemical profile, beta mode ultrasonography for intima media thickness of carotid artery, and ECG determination was carried out. RESULTS: Hypertensive patients in our study exhibited significantly increased abdominal obesity. Blood pressure, fasting and 2 hr plasma glucose (4.62 +/- 0.08 and 5.55 +/- 0.17 mmol/l), and triglyceride (1.47 +/- 0.067 mmol/l) levels were compared to those of control subjects (p < 0.05). The fasting insulin levels and HOMA-IR were also significantly increased and Composite Insulin Sensitivity Index (CISI) reduced compared to controls with p < 0.01. Intima media thickness of the left (0.08 +/- 0.01) and right (0.069 +/- 0.008) CA were both significantly increased in hypertensives (p < 0.01). Correlation analysis showed that IMT of the left carotid artery was significantly associated with triglyceride levels (r = 0.813, p < 0.05) but not with insulin measures such as HOMA-IR and CISI. CONCLUSION: Hyperinsulinemia was observed in our non-diabetic hypertensive patients, but no association was found between IMT and insulin resistance. That IMT of hypertensives was associated with triglyceride levels suggests that high levels of insulin may be related to the development of ATH indirectly through its effects on lipid metabolism in our population.     

Chylous fistula after axillary lymph node dissection: incidence, management, and possible cause

Introduction

Chylous fistula is a known complication in procedures such as neck dissection and aneurysm surgery. However chyle leak that develops after axillary dissection is a rare phenomenon. In this study we have evaluated the incidence, possible cause, and management of chylous fistula that develops after radical breast cancer surgeries.

Material and Methods

Chylous fistula developed in 6 of 1863 patients who underwent axillary dissection. Their records were analyzed in terms of clinical profile and management. A review of the literature regarding the thoracic duct anatomy at its termination was carried out and a hypothesis about the possible cause of chylous leak was suggested.

Results

All 6 patients had procedures on the left side and had varied clinical stages and profiles. The chyle discharge was detected intraoperatively during the primary surgical procedure in 2 patients. The other 4 patients presented with chyle in their drains postoperatively. One patient did not respond to conservative management and underwent reexploration to seal the leak. Injury to the thoracic duct or its aberrant branches is apparently not the cause of chylous fistula in the axilla. The injury to the left subclavian duct or its tributary, which drains aberrantly into the thoracic duct through a valveless junction has been hypothesized to be the source of chyle in the axilla.

Conclusion

Chylous fistula is very unusual after axillary dissection. Most of the chyle leaks in the axilla are manageable through conservative methods; surgical intervention is required rarely in special situations. Injury to the left subclavian duct or its tributary is the possible cause.