CME conducted on july

Contents :

*Academics and Achievements

*National Level Workshop / CME / Conference / Medical Education

*Activities of Academic Body

*Graduation day celebration

*Case reports

J. J. M. Medical College, Davangere.

NEWS LETTER COMMITTEE

Patrons :

Dr. Shamanur Shivashankarappa MLA,

Hon. Secretary, BEA., Chairman, JJMMC

Sri S. S. Mallikarjun.Joint Secretary, BEA

Advisory Board :

Dr. H. Gurupadappa, Director, P. G. Studies & Research

Dr. M. G. Rajasekharappa, Director, General Administration

Chairman :

Dr. Manjunath AlurPrincipal

Editor :

Dr. K. RavindraProfessor of Dermatology

Associate Editor :

Dr. C. S. Santhosh Associate Prof. of Forensic Medicine

Scientific Committee :

Dr. G. GuruprasadProfessor of Paediatrics

Dr. M. G . UshaProfessor of Microbiology

Dr. C. Y. SudarshanProfessor of Psychiatry

Executive committee :

Dr. K. R. Chatura, Professor of Pathology

Dr. M. G. Dinesh, Professor of Surgery

Dr. J. Raghukumar, Professor of Orthopaedics

Dr. G. R. Veena, Professor of Obst. & Gynaecology

Dr. B. R. Uma, Reader in Anaesthesia

Dr. A. R. Suresha, Associate Professor of Ophthalmology

Dr. M. S. Anurupa, Professor of Community Medicine

Dr. B. K. Bharathi, Professor of Biochemistry

Dr. M. Sunitha, Assistant Professor of Physiology

Dr. N. S. Prakash, Reader in Otorhinolaringalogy

Dr. M. B. Siddesh, Associate Professor of Radio-diagnosis

Dr. S. Narendranath, Associate Professor of Pharmacology

Dr. T. V. Pradeep, Assistant Professor of Medicine

"The greatest disease in the West today is not TB or

leprosy ; it is being unwanted, unloved, and uncared for. We can cure

physical diseases with medicine, but the only cure for loneliness, despair, and hopelessness is love. There are many in the world who are dying for a piece of bread but there are many more dying for a little love. The poverty in the West is a different kind of poverty - it is not only a poverty of loneliness but also of spirituality. There's a hunger for love, as there is a hunger for God."

- Mother Teresa

The Chairman / The Principal,

J. J. M. Medical CollegeDavangere - 577 004.

Ph : +91-8192-231388, 253850-59 Ex. 101 / 104Fax : +-1-8192-231388, 253859 www.jjmmc.org

Disclaimer : Views and openions expressed in this newsletter are not directly that of the editor or the editorial board. For any clarification,

author of the article is to be contacted.

ACADEMICS AND ACHIEVEMENTS

02 JJMMC VoiceJuly 2013JJMMC VoiceJuly 2013

ollowing are the academic activities and

achievements of our college faculty from various

departments.F1) Dr.Chatura K. R. presented "Cyto-histo-correlation of

ischemic fasciitis" in Slide seminar at the Launch of

Karnataka Chapter of Indian academy of cytologists, st

SDMMC, Dharwad on 31 March.

2) Dr. Chatura K. R. delivered a lecture on "Impact of

2001 Bethesda system of Cervical Cytology

Reporting" in the CME "Update of Diagnostic

Cytology" Department of Pathology , Sri Devaraj Urs thMedical College on 5 of April 2013.

3) Dr. Chatura K. R. has been nominated to the Executive

council, Karnataka Chapter of Indian Academy of

Cytologists 2013 -14.

4) Dr. Akshi Katyal, first year postgraduate, won the third

place for the poster "Cytomorphology of

myxofibrosarcoma - A see and learn experience"

guided by Dr. Chatura K. R., at Launch of KC-IAC,

SDMMC, Dharwad on 31-03- 2013.

5) Dr. S. S. Hiremath was faculty for Workshop on

"Histotechniques" at SSIMR, Davangere, conducted

by KC -IAP(ID) and delivered a lecture on

"Connective tissue stains" on 14-04-2013.

1) Department of Medicine celebrated the 82nd Birthday

of Dr. H. Gurupadappa, Director for Post graduate

studies, known as Teacher of Teachers, one of the

eminent senior faculty member of J.J.M. Medical

College, Davangere and Karnataka.

2) Dr. Pradeep T. V. Asst. Prof. of Medicine "Serum lipid

profile and Electrocardiographic changes in young

smokers" IJPHS vol.2/no.1/march 2013;2(1): 33 - 38.

Academic Activities of Dr. Sudarshan C. Y.

Delivered a lecture on "Coping Physical and

Psychological changes in Adolescent Males," to high

DEPT OF PATHOLOGY

DEPARTMENT OF MEDICINE

DEPARTMENT OF PSYCHIATRY

school and preuniversity students of Aditya Birla

Educational Institutions Harihar on 1-2-2013. About 300

students with their parents participated in the program

which featured a lively question and answer session at the

end.

Participated in a Mental health Awareness Program

organized by the taluk administration of Jagalur taluk , for

anganwadi workers, ASHA workers, Relatives of

psychiatrically ill patients on 3-2-2013. Delivered a talk on

Mind and Mental Illness - Common myths and Treatment

facilities available.

1) Dr. B. Vidyasagar, delivered the following lectures :-

Diagnosis of tuberculosis beyond sputum examination thand chest x-ray ,on May 13 , at Kapicon 2013,

Mangalore.

Selection of antibiotics for respiratory tract th

infections.0n 25 May, for family physicians,

Davangere.thCOPD acute exacerbation interactive session, on 26

May for physicians, Davangere.

2) Dr. B. P. Rajesh-delivered the lecture on "Reliability of th

chest Xrays in the diagnosis of tuberculosis", on 5

June 2013, for Physicians of Chitradurga.

3) Dr. Arun B. J. delivered the lecture on "Inhaled th

medications in Asthma & COPD". On 7 June, at IMA,

Harapanahalli.

The Department of Neonatology, JJMMC & SSIMS under

the auspices of NNF in association with department of

Peadiatrics, JJMMC, IAP-Davangere District Branch,

Dr. Nirmala Kesaree Paediatric Academic Trust &

Department of Health & Family Welfare conducted its first

novel one-day CME with the theme "President's vision -

Reach the Unreached" for PHC & MHC Medical Officers thof Davangere district on 27 April, 2013. It was conducted

in Bapuji Child Health Institute Auditorium.

DEPARTMENT OF PULMONARY MEDICINE

NATIONAL LEVEL WORKSHOP / CME /

CONFERENCE NEONATOLOGY CME

"Let food be thy medicine and medicine be thy food"- Hippocrates

JJMMC VoiceJuly 2013JJMMC VoiceJuly 2013 03


Dr. Manjunath Alur, Principal, JJMMC & Dr. Sumitra

Devi, District Health Officer were the chief guests while

Dr. P. S. Suresh Babu presided over the CME. The

dignitaries inaugurated the CME by giving an artificial

breath to the Mannequin baby with the concept "Give a

breath, save a life " . Dr. G. Guruprasad read "Brief report"

about CME. This was followed by release of the "CME

Resource Book". Dr. Munavar, District RCH officer & Dr.

Prabhu Patil, District Malaria Officer also participated. Dr.

S. S. Prakash, President, IAP-DDB proposed the Vote of

Thanks. The CME had an attendance of 150 delegates of

which majority were Medical Officers of PHC / MHC's.

Topics chosen dealt with the common Neonatal problems

faced in day to day practice.

The CME began with the delegates being given an

"Overview of Neonatal Resuscitation" by Dr. G.

Guruprasad, Prof., & HOD, Department of Neonatology,

JJMMC as a practical demonstration with all the necessary

equipments. This was followed by talk & demonstration on

the "Art of Newborn Examination" by Dr. Ashwini R. C.,

Asst. Professor Department of Neonatology, JJMMC,

Davangere.

Dr. B. S. Prasad, Professor of Pediatrics & Vice Principal,

SSIMS & RC gave a talk on "Approach to Respiratory

Distress in Newborns".

Dr. Girish G., Asst. Professor of Neonatology, JJMMC,

enlightened the participants about the "Myths & Facts of

Neonatal Jaundice". Dr. P. S. Suresh Babu, Professor of

Pediatrics & Past President IAP-Karnataka State Branch

spoke on "Feeding of LBW infants". The post lunch session

began with an interactive Panel discussion on NEONATAL

SEPSIS with Dr. Guruprasad as Moderator and Dr. Girish

G., Dr. Ashwini R. C. & Dr. Jayalakshmi (Fellow in

Neonatology, JJMMC ) as the Panelists. The risk factors of

Neonatal Sepsis, diagnostic dilemmas and practical tips in

the management of neonatal sepsis were discussed.

Dr. Harsha B. M., Professor of Pediatric Surgery, JJMMC,

spoke on "Surgical Neonate-when and how to transport"

and answered queries of participants on practical aspects

involved during transport of neonate with surgical

problems from periphery to a tertiary referral centre.

This was followed by a session on "Mixed Bag

of Neonatology" in which common neonatal emergencies

were discussed. Dr. Madhu Pujar, Associate Professor

gave a talk on "Neonatal Seizures" & Dr. Ramesh H.,

Professor of Pediatrics spoke on "Management Protocol of

Hypoglycemia in Newborn" .

The concluding talk was given by Dr. Chaitali R. Raghoji

on the" Danger signs in Newborn"- How to identify, when

to start treatment and refer patient to higher centre.

This was followed by an Open House discussion on various

aspects like Neonatal colic, Identification of seizures,

intramuscular injection for Neonatal sepsis, sunlight

therapy for Neonatal Jaundice and timing of surgery for

Esophageal Atresia / Tracheoesophageal Fistula.

Role play "Ruchigintha Schuchi Mukhya" by the nursing

staff of Bapuji Child Health Institute depicted in a hilarious

and entertaining manner the importance of hygiene. It was

well appreciated by the CME delegates.

The CME ended with the award of certificates to the

participants and high tea.

A CME was conducted by the department of Dermatology

on 7-4-2013 in the Library Auditorium. Dr. Prabhakar M.

Sangolli, Consultant Dermatologist & Former Associate

Professor, Department of Dermatology, Dr. B. R.

Ambedkar Medical College Bangalore delivered enriching

talks on:

1. Urticaria: an update

2. Acne: an update

3. Dry skin

Senior Dermatologist and Professor Emirates Dr. K.

Sidappa inaugurated the function. The gathering was

welcomed by Dr. S. B. Murugesh, Professor & HOD,

Department of Dermatology. Dr. K. Ravindra, Professor,

Department of Dermatology, thanked the gathering. A total

of around 100 delegates attended the CME.

DEPARTMENT OF DERMATOLOGY

"Declare the past, diagnose the present, foretell the future"- Hippocrates



DEPARTMENT OF MEDICINE

ACTIVITIES OF DEPARTMENT OF

MEDICAL EDUCATION

thA CME on "Diabetes in Children" organized on 14 April

2013 and following guest lectures were delivered: -

1. "Epidemiology of diabetes in children - global / Indian

scenario" Dr.K.M.Prasanna kumar. Endocrinologist,

MS Ramaiah medical college, Bangalore.

2. "Diagnosis and classification of DM in children" Dr.

Chandrashekar S. Professor, J.J.M. Medical College.

3. "Management of DM in children with insulin" Dr.

Surendra E. M., Professor, J.J.M. Medical College.

4. "Nuts and bolts of monitoring children with diabetes"

Dr. Manjunath Alur, Principal, J.J.M. Medical College.

5. "CGMS and insulin pump in type 1 diabetes" Dr. K. M.

Prasanna Kumar, Endocrinologist, MS Ramaiah

Medical College, Bangalore.

6. "Chronic complications of type 1 diabetes" Dr.

Gurushanthappa S. Professor, J.J.M. Medical College.

7. "Management of DKA" Dr. Vinaya Swami P. M.

Professor, J.J.M. Medical College.

8. "Psychosocial aspects of DM" Dr. K. Sriharsha,

Professor, J.J.M. Medical College.

9. "Auto immunity in Type 1 DM" Dr. U. R. Raaju,

Reader, J.J.M. Medical College.

st1 Basic Course Workshop on Medical Education

Technologies (MET) was conducted for 3 days for our th th

college faculty from 25 to 27 April,2013 in which 27

members participated. This programme was MCI (Medical

Council of India) approved as it was conducted under the

consensus of MCI & MCI's Regional Training Centre,

JNMC, Belgaum. Dr. Manjunath Alur, Principal, JJMMC

inaugurated the programme. Dr. Sunitha Y. Patil, Associate

Professor of Pathology, FAIMER Fellow, Assistant /

Coordinator, DOME, JNMC, Belgaum was the observer &

external resource person. Following faculty of our college

were the resource persons :-

1. Dr. Usha M.G., Prof. of Microbiology & Coordinator

of DOME

2. Dr. Nagamani Agarwal, Prof. of Pediatrics

3. Dr. Deepak G.Udapudi, Prof. of Surgery

4. Dr. Rajini S., Asso. Prof. of Biochemistry

5. Dr. Preethi B. P., Asso. Prof. Biochemistry

6. Dr. Veena M., Asso. Professor of Microbiology

7. Dr. Suneel Reddy, Asso. Prof. of Pharmacology

8. Dr. Jayalakshmi M. K., Asst. Prof. of Physiology

9. Dr. Sunitha M., Asst. Prof. of Physiology

10. Dr. Varadendra Kulkarni, Asst. Prof. of Pathology

11. Dr. Renuka B. G., Asst. Prof. of General Medicine

Dr. Santhosh C. S., Asso. Prof. of Forensic Medicine,

Dr. Sunil Kumar K. B., Asso. Prof. of Pathology,

Dr. Anurupa M., Prof. of Community Medicine took

active role in conduction of programme, in Role plays

& Video shows.

Case discussion on the following topics were organized by

the academic body "Multimodality imaging finding and

clinical aspect in tuberous sclerosis" Department of

Radiology on 16-5-13

"Oesophageal stricture and management" Dr. Siddesh,

Gastroenterologist

"Lumbo-costal vertebral syndrome" by Dept. of

Neonatology

All the faculty members took part actively in the case

discussion.

Guest Lecture on "Infectious disease control" on 5-6-13

Dr. Chetan Jinadatha, M.D., MPH, USA

Guest lecture on "Pain Management" Dr. Naren Raj,

Consultant Anesthetist, Manchester, UK

Case discussion on "Intestinal Obstruction"- surgery C

unit, Bapuji Hospital

ACADEMIC BODY

"The art is long, life is short, opportunity fleeting, experiment dangerous, judgment difficult"- Hippocrates


The graduation day started at 5.30 pm after the arrival of the

guests with a march from the Mother Theresa block to the

Bapuji auditorium with the band on the red carpet. There

was a photo session for the whole batch. After the photo

session, all the students gathered inside the auditorium .The

program started with invocation. Dr. Shukla Shukla Shetty,

professor, department of OBG welcomed the gathering.

This was followed by lighting the lamp. Dr. Prasanna

Anaberu, professor, department of orthopaedics,

introduced the chief guest Dr. C. V. Manjunath,

cardiologist, director of SJICR, Banglore. Dr. C. V.

Manjunath inspired the students with the stories from his

medical experience about compassion, logic, common

sense and how to deal with all aspects of patient care. Sri S.

S. Mallikarjun, Joint Secretary, BEA, Chairman of SSIMS

and former youth and sports minister addressed the

gathering. Dr. Alur Manjunath, our beloved principal also

spoke on the occasion. Junior doctor's association president

Dr. Sumeeth Kumar read out the batch report containing the

academic, cultural and sports achievements of the batch.

Dr. Kavya Reddy, treasurer, JDA gave an outlook of the

undergraduate life experience of the batch. Also present on

stage were Dr. Gurupadappa, Director of PG studies, Dr. M.

G. Rajashekarappa, Director general Administration,

JJMMC, Dr. Shivswamy Sosale, cardiologist, BMC heads

of all the departments.

th thGraduation Day Celebration of Batch 2007 on 24 and 25 March 2013

The graduation of the students began with the distribution

of certificates and the medals to the students. Dr. Belgundi

Preeti received gold medal from the Apollo group of

hospitals Banglore by the representatives Dr. Sahana

Govindaiah, deputy medical superintendent and Mr.

krishnamurthy, senior manager-admn & HR for being the

best outgoing student of the batch. Dr. Prashanth R. R. was

awarded gold medal from the Alur Trust for scoring the

highest marks in medicine.

The fresh graduates took the Hippocratic Oath under the

guidance of Dr. Ravindra Banakar, senate and syndicate

member of RGUHS. Dr.Belgundi Preeti, vice-president,

JDA thanked the gathering with the vote of thanks. The

parents of all the fresh graduates participated in the

function. Grand dinner was arranged after the ceremony. thOn 25 march a cultural program was arranged by the batch

of 2007.

Name of the Topic Name of Presenter

Name of the Guide / Other Authors

Venue & DateSl.No.

A cyto- histomorphological correlative study of endometrium

Granuloma in testis- A dilemma

FNAC spleen in diagnosing primary myelofibrosis

Malignant testicular germ cell tumour

Angioimmunoblastic T-cell lymphoma

Gaucher's disease

Leukemic lymphadenopathy

1

2

3

4

5

6

7

Dr. Boobalan S.

Dr. Ananthvikas J.

Dr. Nagalakshmi D. N.

Dr. Ajit Pratap Singh Panayach

Dr. Shweta Puri

Dr. Ranjana R.

Dr. Neethu R.

Dr. S. S. Hiremath

Dr. Chatura K. R.Dr. Sunilkumar K. B.

Dr. Hiremath S. S.Dr. Suresh Hanagavadi

Dr. Hiremath S. S.Dr. S. B. Patil

Dr. Hiremath S. S.

Dr. Hiremath S. S.

Dr. Hiremath S. S.Dr. Suresh Hanagavadi

Karnataka chapter of Indian Academy of CytologistsSDMCMS, Dharwad on31-03-2013

Postgraduate Section: Dept. of Pathology: Posters presented by postgraduates


"Cure sometimes, treat often, comfort always"- Hippocrates


Name of the Topic Name of Presenter


Venue & DateSl.No.

Bronchioloalveolar carcinoma -The mystery lung cancer

Left supraclavicular lymphnode metastasis of ovarian carcinoma - an uncommon presentation

Myxofibrosarcoma- A see and learn experience

Cytological diagnosis infiltrating squamous cell carcinoma of buccal mucosa

Cytomorphology of Anaplastic large cell lymphoma

Intraoperative cytology of mixed germ cell tumor ovary

Cytological evaluation of polymorphous low grade adenocarcinoma- parotid

Malignant melanoma on FNAC-Two case reports

Recurrent soft tissue tumour - A case report

Salivary duct carcinoma - A Pitfall on FNAC

Dr. Sreelekha B. V.

Dr. Priya C.

Dr. Akshi Katyal

Dr. Suchetha K. R.

Dr. Geetha D. H.

Dr. Trupti Deshpande

Dr. Prashanth R.

Dr. Abhijit Kalita

Dr. Rama Reddy Tetali

Dr. Bhuvana T.

Dr. Hiremath S. S.

Dr. Hiremath S. S.Dr. Nikethan B.

Dr. Chatura K. R.Dr. Hiremath S. S.

Dr. Hiremath S. S.

Dr. Hiremath S. S.

Dr. Hiremath S. S.


Dr. Hiremath S. S.Dr. Arijit Roy


Dr. Chatura K. R.

Karnataka chapter of Indian Academy of CytologistsSDMCMS, Dharwad on31-03-2013

8

9

10

11

12

13

14

15

16

17

Oral Presentation : Dr Abhijit Kalita : Penile neoplasia: OLD wine in a NEW bottle of morphology, stGuided by Dr. Chatura K. R. at 61 Annual conference of IAPM, APCON 2012, Jamnagar, Gujarat, December 2012

DEPT. OF MEDICINE

Name of the Topic Name of the Guide / Other Authors

Venue & DatePresen-tation

Sl.No.

Name of Presenter

Acute ischemic Infarct in MCA territory following Russell's Viper bite

Thyroid functions in chronic Renal failure patients

Congenital heart disease single ventricle with malposition of great vessels with pulmonary stenosis

Study of Carotid Intima media Thickness among Type-2 DM, HTN & Diabetic hypertensive patients

Poster

Platform

Poster

Platform

Dr. Shardulkumar Dubey

Dr. Shardulkumar Dubey

Dr. P. VamseeKrishn

Dr. P. Vamsee Krishna

Dr. K. Sriharsha

Dr. P. E. DhananjayaDr. Shrinivas A. Patil

Dr. K. Sriharsha

Dr. Vinayswamy P. M.Dr. Ashok K.

KAPICON - 2013th th

26 to 28 April 2013 Mangalore.

1

2

3

4


"Natural forces within us are the true healers of disease"- Hippocrates



Name of the Topic Name of the Guide / Other Authors

Venue & DatePresen-tation

Sl.No.

Name of Presenter

Alexia without Agraphia

Sturge weber syndrome - case report

Endoscopic esophageal stricture dilatation without Fluoroscopy

Clinical and Histopathological study of Nephrotic syndrome in adults

Brain Metastasis from Hepatocellular carcinoma (HCC)

A Study of Coronary artery involvement in Diabetics & non-Diabetics with Acute coronary sysndrome

Eight and Half Syndrome

To assess the prevalence of hyperglycemics with RCBG in rural community of South India.

Pneumatic balloon dilatation of achalasia cardia

5

6

7

8

9

10

11

12

13

14

15

16

17

Poster

Poster

Poster

Platform

Poster

Paper

Poster

Platform

Platform

Dr. Deepak S. V.

Dr. Basavanagowda G. M.

Dr. Shankargouda Patil

Dr. Shankargouda Patil

Dr. Chirag D.

Dr. Chirag D.

Dr. Manjunath P. R

Dr. Manjunath P. R.

Dr. Prashanth D. C.

Dr. L. KrishnamurthyDr. S. M. YeliDr. Vishwakumar S. N.

Dr. L. Krishnamurthy

Dr. E. R. SiddeshiDr. S. N. Vishwakumar

Dr. Rajeev Agarwal Dr. Aditya Lajami

Dr. S. M. Yeli

Dr. Srinidhi M. S.Dr. P. Mallesh

Dr. L. KrishnamurthyDr. S. M. Yeli

Dr. Vishwanath B. M.

Dr. E. R. SiddeshiDr. S. N. VishwakumarDr. S. R. HegdeDr. SrinivasDr. Keshav

KAPICON - 201326th to 28th April 2013 Mangalore.

Organophosphate induced delayed polyneuropathy

Isolated systolic Hypertension in elderly ; evaluation of cardiac status and study of co-existing cardiovascular risk factors

Spreading vasculitis of unknown etiology - a case report

Dyke Davidoff masson's syndrome

Poster

Paper

Poster

Poster

Dr. Prashanth D. C.

Dr. Suresh S. R.

Dr. Suresh S. R.

Dr. Phiji Mathews Philipose

Dr. Manjunath AlurDr. Chandrashekar S.Dr. Surendra E. M.

Dr. Thippeswamy A. P. Dr. Rahul S. Patil

Dr. S. M. Yeli

Dr. B. D. ChavanDr. Malathesha M. K.

"It's far more important to know what person the disease has than what disease the person has"-Hippocrates



Dr.Shankargowda Patil Final Year Post Graduate Student in General Medicine received the Best Paper award in

Nephrology section for "Clinical and Histopathalogical Study of Nephrotic syndrome in adults" at KAPICON - 2013 in

Mangalore, Karnataka, under the Guidance of Dr.Rajeev Agarwal. Prof. of Medicine.

DEPARTMENT OF PSYCHIATRY

Name of the Topic Presen-tation

Sl.No.

A Clinical study of microvascular complications - in a newly diagnosed Type 2 DM

Clinical Spectrum of Pulmonary Tuberculosis in HIV sero positive persons with reference to CD4 count

Paper

Paper


Venue & DateName

of Presenter

Dr. Suman G. R.

Dr. Jairaj

Dr. Manjunath Alur Dr. Mohan R.

Dr. Rajasekharappa G.Dr. S. Rajakumar

KAPICON - 2013th th

26 to 28 April 2013 Mangalore.

18

19

Name of the Topic Presen-tation

Sl.No.


Venue & DateName

of Presenter

Psychiatric morbidity in students

Study of Psychosocial profile in suicide attempters in tertiary care hospital

Psychiatric morbidity in prisoners

Temperament & emotional problems in children with specific learning disability-Teacher's perceptio

Emotional quotient & coping skills in junior doctors

Psychiatric morbidity in students & non-student population-A comparative study

1

2

3

4

5

6

Dr. Karthik U. M.

Dr. Nivedita

Dr. Mruthyunjaya Dr. Anupama M.Dr. GangadharDr. RoopeshDr. Raghu

Dr. Mruthyunjaya

Dr. Harish Kulkarni

Dr. Karthik U. M.

Dr. Shamshad Begum

Dr. M.Anupama

Dr. Anupama M.

Dr. Sudarshan C. Y.Dr. Shamshad Begum

Dr. K. Nagraj Rao Dr. Shamshad Begum

KANCIPS held at Mangalore Dec 2012

Poster

Poster

Poster

Paper

Paper

Poster

ANCIPS 2013 held at Bangalore January 2013

"Extreme remedies are very appropriate for extreme diseases"-Hippocrates


Introduction

Case Report

Discussion

Urothelial carcinoma is the most common malignancy of the urinary tract and is the second most common cause of death among genitourinary tumors. Bladder cancer is related to age and exposure to environmental carcinogens, 3 times more common in men than in women, rare in persons less than the age of 40 years and typically nonaggressive and well differentiated.

We gave a brief insight into the WHO 2004 grading scheme which has replaced the 1973 and 1998 WHO classification system of urothelial neoplasia.

A 15yr boy presented with the history of hematuria for past 6 months. He was evaluated thoroughly and found to have a bladder growth on ultrasound. There was no metastasis found on metastasis work up. He underwent TURBT under spinal anaesthesia (Fig1). The growth was completely removed (Fig 2) and sent for histopathology examination. The histopathology report gave an impression as Papillary Urothelial Neoplasm of Low Malignant Potential (PUNLMP), (Fig 3, 4). The boy was relieved of symptoms and is on regular follow up for past 2 months.

PUNLMP, short for papillary urothelial neoplasm of low malignant potential, is an exophytic (outward growing), (microscopically) nipple-shaped (or papillary) pre-malignant growth of the lining of the genitourinary tract (the urothelium).

PUNLMP is pronounced pun-lump, like the words pun and lump.

PUNLMP is a papillary growth with minimal cytological atypia that is more than seven cells thick and is generally solitary and located on the trigone and is composed of thin papillary stalks, where the polarity of the cells is maintained and the nuclei are minimally enlarged. PUNLMP has a low proliferation rate and is not associated with invasion or metastases. PUNLMP is different from a benign papilloma in that a PUNLMP has a thicker cell layer and large nuclei with occasionally mitotic figures. The male to female ratio for PUNLMP is 5:1, and the mean age is 65. PUNLMP can recur within the bladder in 35% of cases, but progression is rare, occurring in less than 4%. PUNLMP is relatively rare with a prevalence of 0-3.5%

PUNLMPs are exophytic lesions that appear friable to the naked eye and when imaged during cystoscopy. They are definitively diagnosed after removal by microscopic

PAPILLARY UROTHELIAL NEOPLASM OF LOW MALIGNANT POTENTIAL (PUNLMP) - CASE REPORT

examination by pathologists. Histologically, they have a papillary architecture with slender fibrovascular cores and rare basal mitoses. The papillae rarely fuse and uncommonly branch. Cytologically, they have uniform nuclear enlargement.

They cannot be reliably differentiated from low grade papillary urothelial carcinomas using cytology, and their diagnosis (vis-a-vis low grade papillary urothelial carcinoma) has a poor inter-rate reliability.

The WHO 2004 grading scheme is used routinely and has replaced the 1973 and 1998 WHO classification system. The elimination of the grade 1, grade 2, and grade 3, 1973 WHO system is collapsed into low grade or high grade in the 2004 WHO classification. This system lacked reliability in terms of recurrence, invasion, metastasis and therefore failed to stratify tumors accurately .In 1998, the International Society of Urological Pathology (ISUP) developed a new nomenclature to better reflect the recurrence and progression rates of urothelial cancer. In 2004, the WHO adopted the ISUP recommended staging system and is the standard histologic nomenclature for urothelial carcinoma.

WHO grading scheme for urothelial malignancy

2004 World Health Organization Classification of Nonivasive and Invasive Urothelial Neoplasia

Noninvasive Urothelial Neoplasiahyperplasia (flat and papillary)Reactive atypiaAtypia of unknown significanceUrothelial dysplasia (low-grade intraurothelial neoplasia)Urothelial carcinoma in situ (high-grade intraurothelial neoplasia)Urothelial papilloma Urothelial papilloma, inverted typePapillary urothelial neoplasm of low malignant potential Noninvasive low-grade papillary urothelial carcinoma Noninvasive high-grade papillary urothelial carcinoma Invasive Urothelial NeoplasiaLamina propria invasionMuscularis propria (detrusor muscle) invasion

From Montironi R, Lopez-Beltran A. The 2004 WHO classification of bladdertumors : a summary and commentary. Int J Surg Pathol 2005 ; 13 (2) : 143-53

"Whereever the art of medicine is loved, there is also a love of humanity"-Hippocrates

JJMMC VoiceJuly 2013JJMMC VoiceJuly 201310

Clinical Significance of Different Non-Muscle_invasive Urothelial Cancer Categories in WHO 2004 Grading System

CIS, carcinoma in situ; N/A, not applicable ; WHO, World Health Organization.From Montironi R, Lopez-Beltran A. The 2004 WHO classification of bladder tumors : a summary and commentary.Int J Surg Pathol 2005 ; 13 (2) : 143-53.

PapillomaPapillary Neoplasm of Low

Malignant PotentialLow-grade Papillary

CarcinomaHigh-grade Carcinoma

(Papillary and CIS)

Recurrence (%)

Grade progression (%)

Stage progression (%)

Survival (%)

0-8

2

0

100

27-47

11

0-4

93-100

48-71

7

2-12

82-96

55-58

N/A

27-61

74-90

Special thanks to, Dr. K. K. Suresh, Department of Pathology, JJMMC, Davanagere.

Figure 1: Intra operative picture of the papilloma

Figure 2: Specimen after resection.

Figure 3: (1) Low-power view of tumor of Figure 4: (2) High-power view of the same tumor. lowmalignant potential (LMP). The cellular polarity is retained

and the superficial umbrella cell layer is intact.Dr. Naveen H. N. Asst. Prof, Urology, Bapuji Hospital

Dr. Deyonna Fernandes (Surgery Post graduate)

Histologic Characteristics of Noninvasive Papilary Urothelial Tumors of the Bladder According to the WHO

From Montironi R, Lopez-Beltran A. The 2004 WHO classification of bladder tumors : a summary and commentary. Int J Surg Pathol 2005 ; 13 (2) : 143-53.

PapillomaPapillary Neoplasm of

Low Malignant Potential (PUNLMP)

Low-grade PapillaryCarcinoma

High-grade Papillary Carcinoma

Architectural Features Papillae

Organization of cells

Cytologic Features Nuclear size

Nuclear shape

Nuclear chromatin Nucleoli

Mitoses Umbrella cells

Delicate

Identical to normal urothellum

Identical to normal urothellum Identical to normal urotheliumFine Absent

AbsentUniformly present

Delicate, Occasionally fused, not branchingOrdered, Polarity Identicalto normal urothellum any thickness, cohesive

May be enlarged but uniformElongated, round to ovaluniformFineAbsent to inconspicuous

Rare, basalPresent

Fused, branching

Predominately ordered ,minimal crowding and minimal loss of polarity ; any thickness, cohesive

Enlarged with variation in sizeRound to oval, slight variation in shape and contourmild variationUsually inconspicuous

Occasionally at any levelUsually present

Fused branching

Predominately disordered with frequent loss of polarity, variable thickness, discohesive

Enlarged with variation in size ready visible moderate to marked pleomorphismModerate to marked variation. Hyperchromasia.

Multiple prominent nucleoli maybe present Usually frequent, at any level Usually absent

"Walking is man's best medicine"-Hippocrates


JUVENILE NASOPHARYNGEAL ANGIOFIBROMA - RARE CASE REPORT

ABSTRACT

A 12 year old male, presented with left sided progressive nasal obstruction and recurrent epistaxis since 5 months. History, clinical examination and imaging pointed to the diagnosis of Juvenile Nasopharyngeal Angiofibroma (JNA).

JNA is a relatively uncommon neoplasm occurring almost exclusively in adolescent males.It is histologically benign, but locally aggressive vascular tumor. It is the most common benign neoplasm ofnasopharynx. Surgery is the main modality for management of this tumor.

INTRODUCTION

JNA is a rare high risktumour of adolescent males.It accounts for less than 0.5% of head and neck tumours.The most common presenting symptoms are severe recurrent epistaxis with persistent nasal obstruction.As disease progresses,facial deformities,proptosis,blindness and cranial nerve palsies may occur.Diagnosis is based on a careful history, clinical features and radiological examination.Different treatment modalities are available-the definitive being surgical extirpation and most recent is endoscopic excision.

CASE REPORT

A 12 year old male patient came with complaints of left sided progressive nasal obstruction and recurrent bouts of epistaxis and voice change(nasal intonation) since 5 months. Medical, family and personal history were noncontributory. General physical examination revealed a moderately built and nourished adolescent male with swelling on left side of cheek. Anterior rhinoscopic examination revealed blood stained mucoid discharge and deviated septum to left. Posterior rhinoscopy revealed a pinkish mass in the nasopharynx. Oropharyngeal examination was normal.

Figure 1-pre op picture of the patient

CT-PNS showed an intensely enhancing lobulated mass of 2.5x2.1 cm arising from posterior choana extending into left sphenopalatine foramen and laterally to pterygopalatine fossa causing remodelling, deviation of

septum to right and expansion of left pterygopalatine fossa. Routine examination of blood, urine, CXR, ECG revealed no abnormalities. Based on clinical features and radiological evaluation, it was diagnosed as a case of Juvenile nasopharyngeal angiofibroma-Stage II b. Angiography and embolisation were not done due to unavailability.

Figure 2-axial,sagittal and coronal cuts showing mass in nasopharynx

Surgical excision under GA through lateral rhinotomy approach was planned. After sufficient pre-op measures(including 4 units of fresh blood)patient was operated using hypotensive anaesthesia, in supine and 15 degree head up position. Through left lateral rhinotomy the tumour was approached by medial maxillectomy with exposure of left maxillary antrum and sphenopalatine foramen from where the tumour has originated.Tumour was pushed to the nasopharynx with digital pressure, dissecting subperiosteally. Whole mass was removed along with its extensions. Post nasal and anterior nasal packing done. Incision was closed in layers. Per operative bleeding was around 1L.So 2 units of blood transfusion was done intraoperatively.

Figure 3- Intraop images

Nasal packs were removed after 48 hours and there was no bleeding. Mild soft tissue swelling was present on left side. No visual disturbances or epiphora. Patient is doing well.

"Whenever a doctor cannot do good, he must be kept away from doing harm"-Hippocrates


DISCUSSION

JNA is a highly vascular, benign, yet locally invasive neoplasm seen in adolescent males. Its exclusive occurrence in males suggests a hormonal influence. The site of origin is most likely near sphenopalatine foramen. It expands laterally via pterygopalatine fossa to infratemporal fossa, medially to anterior nasal cavity and related sinuses. It can have intracranial extension into anterior and middle cranial fossa via preformed pathways or by destroying bone.

Gross pa thology usua l ly showed a sess i le , lobulated,rubbery dark red to tan grey unencapsulated mass, composed of an admixture of vascular tissue and fibrous stroma.

JNA usually presents with unilateral nasal obstruction and recurrent epistaxis. Other features include facial swelling, proptosis, diplopia, conductive hearing loss, mucopurulent rhinorrhoea, headache, nasal speech, anosmia etc,10-20% can have intracranial extension at time of presentation.

Plain lateral X-ray of skull showed anterior bowing of posterior wall of maxillary sinus. CT with contrast shows an enhancing soft tissue mass arising from nasopharynx, widening of sphenopalatine foramen and expansion of pterygopalatine fossa. MRI showed a vascular tumour with flow voids within the sinus. Biopsy is contraindicated due to risk of haemorrhage. Diagnosis is based on its typical presentation, clinical examination and radiological investigations..

Definitive diagnosis is established by angiography, characteristic angiographic appearance in JNA is tumour blush and absence of venous filling. Major arterial supply is ipsilateral internal maxillary artery and in 1/3rd cases ascending pharyngeal artery. If there is infra-temporal or intracranial extension, contralateral ECA, ICA and CCA also contribute.

There are various staging systems for JNA-Chandler's, Session's, Fisch's, Radkowski's etc. Various treatment modalities are-Surgical, Radiotherapy, Hormonal, Chemothe rapy, C ryo the rapy, Sc l e ro the rapy, Electrocoagulation and Gamma knife surgery. Surgical excision is the treatment of choice for extracranial lesions. Choice of surgical approach is determined by pre op imaging revealing the site and extent of lesion. Various approaches include transpalatal, medial maxillectomy approach via lateral rhinotomy or midfacial degloving, Le-Fort I osteotomy, maxillary swing, trans-mandibular, trans-hyoid etc. Trans-nasal endoscopic tumour resection is the mainstay of surgical resection in present era.

Radiotherapy has been used for reccurence after surgery and those with intracranial extension. External beam radiation is given as 30-35 Gy in 15-18 fractions for 3 weeks. Hormonal therapy with diethyl stilbesterol and flutamide (non steroidal androgen antagonist) has been used as an adjuant therapy to primary surgical treatment.

CONCLUSION

JNA is an uncommon, benign and extremely vascular tumour seen exclusively in adolescent males. Diagnosis is based on history, physical examination and radiographic findings. CT scanning is invaluable for evaluating tumour extent. Angiography combined with embolisation aids surgeons in identifying the main feeding vessels and decreasing intraoperative blood loss. Surgery is the main stay of therapy with radiation therapy reserved for inoperable masses.

REFERNCES

1. Scott-Brown's Otorhinolaryngology $ Head and Neck Surgery(7th edition)

2. Cumming's Otorhinolaryngology & Head & Neck Surgery(5th edition)

3. Eugene Myer's Operative Otolaryngology(2nd edition)

4. Otolaryngologic Clinics of North America-Nov.86

5. Indian Journal of Otolaryngology & Head and Neck Surgery(July-Sept 2012)

6. Journal of Laryngology & Otology 2008;122;1185-9 endoscopic approach to JNA

7. Laryngoscope 2005;115:1201-7 endoscopic versus traditional approaches for excision of JNA

Figure 4-specimen post op Figure 5-patient post op

Dr. K. P. Basavaraj, Professor, of E.N.T

Dr. K. B. Chandrappa, Professor, of E.N.T

Dr. Lakshmi Prasenajith, PG in E.N.T

"A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit from his illnesses"

-Hippocrates


INTRA ORAL RECONSTRUCTION IN ADENOID CYSTIC CARCINOMA WITH EXTENDED NASOLABIAL

SKIN FLAP - A RARE CASE

ABSTRACT

INTRODUCTION

CASE REPORT

Facial reconstruction relies on creativity of surgeons as well as clear understanding of local flaps. Large defects following resection of head and neck tumors can present as a challenge for reconstructive surgeon. We present a case of adenoid cystic carcinoma of face and oral cavity managed by combined wide excision and extended nasolabial rotation flap reconstruction. Proper planning and staging of surgical procedure and use of local flaps gave us good aesthetic and facial outcome.

KEY WORDS : adenoid cystic carcinoma (ACC), nasolabial rotational flap, intra oral reconstruction.

The adenoid cystic carcinoma is a rare malignant tumor of head and neck affecting both minor and major salivary glands along aero-digestive tract. It includes approximately 10% of all salivary neoplasms and 30% of minor salivary glands. It is well known for its slow progression, perineural invasion, delayed direct distant metastasis. The goals of management in cases of carcinoma of head and neck include preservation of life by surgical ablation with combined radiotherapy and focussing on better facial aesthesis and oral function to improve quality of life. Quality of life has been found to be improved in those who have undergone vascularized nasolabial flap reconstruction. The subcutaneous pedicled nasolabial flap appears to have been originally described in works of Susruta in 600 BC in India. For centuries there after nasolabial flap was used primarily in external nasal reconstruction, but several authors have reported favourable outcome when this flap was used to cover oral cavity defects.

Here we report a case of adenoid cystic carcinoma of minor salivary glands managed with wide excision of tumor and intra oral reconstruction using extended nasolabial flap, first of its kind to be reported in India.

A 60 Year old female patient, tobacco chewer, presented with a recurrent swelling over right cheek since 5 years, progressively increasing in size since one month, associated with pain on chewing and difficulty in opening mouth since one month. She had been operated for same complaint 5 yrs back at private hospital. On examination of cheek and oral cavity, a diffuse solitary swelling over right

side, with bosselated surface inside oral cavity and smooth surface over right cheek, hard in consistency, superior border was ill defined due to extension of tumor into infratemporal fossa and inferior border was well made out and the swelling decreased in size on clenching of teeth. Skin over swelling was pinchable (Fig1,2,3). There was weakness of the buccal branch of facial nerve. No lymphadenopathy. On X-ray PNS soft tissue opacity noted around right maxillary region extending into pterygo palatine fossa with no underlying bony erosions. Fine needle aspiration cytology showed features suggestive of adenoid cystic carcinoma. On Chest X-ray showed no metastasis to lungs.

Based on above findings a clinical diagnosis of ACC of minor salivary gland T4a N0 M0, Stage 4b and patient was taken for wide excision of tumour with extended nasolabial rotational skin pedicle flap for reconstruction of oral cavity.

Under general anaesthesia with nasal intubation, incision was outlined on the right cheek for raising inferiorly based extended nasolabial flap with keeping in consideration tumor location, medial incision of flap precisely followed nasolabial fold in superior two thirds and inferior third 2-3mm medial to fold, apex 1 cm below medial canthus up to angle of mouth lateral to the commissure (Fig4). This design allowed the length of 7-8 cm and width about 4 cm maximum at base with pedicle, and hence less distortion after flap transfer and allowed improved arc of rotation. Incision at base of pedicle was further deepened medially into oral cavity upto 3rd molar including tumor and laterally up to upper border of ramus of mandible for dissecting the tumor. Tumor was dissected along with few masseter fibers laterally and buccal mucosa medially along the extension. Superiorly while dissecting the tumor in inferior temporal fossa, pterygoid plexus of veins were injured and packs were placed in situ just below orbital plate to achieve haemostasis. Skin flap was rotated at base of pedicle and placed inside oral cavity (Fig5). After placing the flap, donor site over right cheek was closed by primary suturing of medial and lateral limb upto angle of mouth bringing the scar in line of nasolabial fold. A small triangular area was left inferiorly at the base of the flap to preserve vascularity of flap pedicle and was planned to be divided after two weeks. On third week patient will be subjected to radiotherapy. Post operatively packs were removed on 3rd post operative day and postoperatively uneventful. (Fig7, 8)

"Healing is a matter of time, but it is sometimes also a matter of opportunity" -Hippocrates


DISCUSSION

Adenoid cystic carcinoma accounts for 60% of all minor salivary gland neoplasms, most common occurrence of ACC is palate and presents as submucosal swelling .ACC is well known for its prolonged clinical course, perineural invasion with tendency of delayed distant metastasis and multi local recurrence rate of 42% .It is commonly seen in 5th to 6th decade of life. Histopathologically ACC is categorized into three growth patterns solid, cribriform and tubular. Loco-regional recurrences are more common in cribriform forms and poor prognosis in solid forms. Fine needle aspiration cytology is preliminary diagnostic tool for malignancies of head and neck, a safe procedure well tolerated with no tumor seeding to surrounding tissue and histopathology of biopsy specimen being confirmatory diagnosis. The optimal therapy for ACC of the head and neck has not been established. The choice of therapy is affected by site, stage, histologic grade, and biologic behaviour of the ACC. There are a number of publications that address the efficacy of surgery and radiation therapy in the treatment of ACC of the head and neck.

In above case ACC was managed surgically with extended nasolabial skin flap. Several methods are described for reconstructing of oral cavity defects either pedicled or free flap. The pectoralis major flap a pedicled flap is commonly used for this purpose. However, this flap is bulky associated with donor site morbidity. Likewise the forearm free flap has also become more preferable reconstruction method .It offers a large surface of thin pliable skin that allows for complex reconstruction but unfortunately donor site morbidity rates are quite high. This makes nasolabial flaps ideal for reconstruction of large intraoral defects. The nasolabial region is well known donor site for variety of flaps and provides an excellent texture and colour. The nasolabial flaps are superior and inferiorly based. An inferiorly based flap is useful in reconstruction of oral lip, oral commissure and anterior aspect of floor of mouth while superiorly based flaps used for reconstruction of ala and tip of the nose, lower eyelids and cheek .The choice of pedicle is based on site of defect and thickness of donor tissue. The nasolabial flaps are raised with skin and subcutaneous tissue to ensure good blood supply, although remaining superficial to facial muscles. The base of the flap is above the level of angle of the mouth, as just below several branches of from facial artery and inferior labial artery

which passes into subcutaneous tissue and skin of nasolabial region further assuring abundant blood supply and lymphatic drainage to and from the flap so less chances of flap edema and flap necrosis. The terminal branches of facial nerve lie deep to facial muscles and are not endangered by flap elevation. The skin flap length and breadth are adjusted in ratio of 4:1 to fill the defect without tension and permit safe closure of donor site in two stage procedure; pedicle will be separated from the flap by 14 to 21 days .The scar line lie along nasolabial fold giving good cosmetic outcome. Radiation therapy in cases of ACC is by photon irradiation therapy which will recur locally with time and usually doses of 60 Gyc or more may be beneficial in minimal residual microscopic disease. The conclusion is that neutron radiotherapy is effective treatment compared with neutron and photon irradiation, for patients with gross residual disease and achieves excellent loco regional control in patients without evidence of gross disease.

PICTURES

Fig. 1 & 2: Adenoid Cystic Carcinoma Right Side of Face and Oral Cavity.

Fig.3 : Acc Extending into Oral Cavity from 1st Upper

Molar to 3rd Molar

Fig. 4 : Incision Outlined Over Right Cheek for Raising

Extended Naso Labial Flap and Tumor being Lateral

Fig.5: Rotation of Nasolabial Flap at base and Placing

inside Oral Cavity

Fig. 6 : Acc Specimen at Recipient Site.

"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health"

-Hippocrates


Fig.7: On Postoperative 2nd Week - Operated Scar in line of Nasolabial fold with Pedical Seperated from flap.

Fig.8: Skin Flap Placed at Recipient Site inside Oral Cavity at 2nd Week.

Dr. K. C. Shivamurthy, Prof. & Head of Plastic Surgery.

Dr. Deepak K. Post-graduate, Dept. of General Surgery.

MULTIMODALITY IMAGING AND CLINICAL ISSUES IN TUBEROUS SCLEROSIS- A CASE STUDY

A 38 year old female patient was referred for ultrasound examination of the abdomen to evaluate the cause of abdominal pain. Patient stated that she experienced pain of mild to moderate severity in the upper part of the abdomen which improved with analgesic use but did not completely subside. She said she first noticed her complaints two years before this hospital visit.

Ultrasound examination of the abdomen revealed grossly enlarged kidneys that were highly echogenic. The parenchyma of both kidneys was observed to be replaced by multiple echogenic masses. Structural disorganization of the kidneys was highly evident.

The enlarged kidneys obscured visualization of other structures. A diagnosis of bilateral renal angiomyolipomas was made.

Ultrasound examination disclosed bilateral renal echogenic masses.

Renal angiomyolipomas can occur in isolation. However multiplicity, bilaterality and gross renal distortion raise suspicion for tuberous sclerosis. Furthermore, the characteristic facial lesion of adenoma sebaceum as shown in the photograph prompted a search for other lesions.

Following a diagnosis of renal angiomyolipomas, additional imaging was considered to evaluate the presence

of other lesions of Tuberous Sclerosis.Patient underwent Roentgenologic Studies of the head, CT scan of the brain and abdomen and MRI examination of the Brain.

CT scan images of the abdomen in axial and coronal views shows multiple fat density masses in bilateral kidneys with marked renal enlargement and architectural distortion with mechanical effects on the pelvicalyceal system as shown in the third image.

R e f o r m a t t e d Sagittal and coronal CT sections of the abdomen viewed in the bone window reveal multiple bony i s l a n d s i n t h e lumbosacral spine.

CT slice through the lower part of the thorax reveals a cystic lucency in the right m i d - l o b e w i t h f e w traversing septations within the same, suggesting cystic lymphangioleiomyoma.

"Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed" -Hippocrates


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ATTENTION PLEASE

he submission for the next issue (October 2013) thTof the News Letter should be done before 10

September 2013. Photos should be in JPEG format.

Please send the material in the form of soft copy as

well as hard copy to the department Co-ordinator.

X-ray studies of the skull show a calcific focus in the left para-sagittal region.

Axial sections of brain CT revealed multiple subependymal nodular calcifications.

Post-contrast CT brain shows few enhancing subependymal nodules.

Left to right : T1 weighted axial brain MRI, T2 axial, gadolinium enhanced and FLAIR axial sections

T1 axial sections show few enhancing subependymal nodules

T2 section shows presence of nodules along with a small white matter cystic lesion in the right parieto-occipital white matter. FLAIR image shows multiple cortical tubers.

DIAGNOSIS: On the basis of the radiological findings of bilateral renal angiomyolipomas, lung cystic lymphangioleiomyomatosis, subependymal calcifications, nodules and cortical tubers in the brain, a diagnosis of Tuberous Sclerosis was made.

DISCUSSION:

TS is an autosomal dominant disorder characterized by the tendency to form multiple hamartomatous lesions in various tissues of the body.

TS is caused by mutations in either TSC1 or TSC2. TSC2 mutations are seen in 75% cases, more so in de novo cases. They tend to be much more severe.

TS1 maps to chromosome 9 whereas TSC 2 maps to 16. The proteins encoded are hamartin and tuberin respectively

The disease has an incidence that varies in different studies from 1 in 10000 to 1 in 50000

The classical clinical triad of facial adenoma sebaceum, seizures and mental retardation is seen in less than fifty percent of the cases and therefore the radiologic hallmarks of this disease have universally been accepted as sufficient evidence for diagnosis

DIAGNOSTIC CRITERIA

MAJOR CRITERIA

Facial angiofibroma or forehead plaque, Non-traumatic ungual or periungual fibroma, Hypomelanotic macule (three or more), Shagreen patch, Cortical tubers, SEN, SEGA, Cardiac Rhabdomyoma/s, LAM, Renal angiomyolipomas, Nodular retinal Hamartomas

MINOR CRITERIA

Dental pitting, Hamartomatous rectal polyps, Bone cysts and islands, Cerebral white matter migration lines, Gingival fibromas, Retinal achromic patch, Confetti lesions, Renal cysts, Non-renal hamartomas

DEFINITE TS - 2 major or 1 major and 2 minor criteria

PROBABLE TS - 1 major and 1 minor criteria

POSSIBLE TS - 1 major or 2 or more minor criteria

Adapted from Roach ES, Gomez MR, Northrup H: tuberous sclerosis complex consensus conference - revised clinical diagnostic criteria. Journal of child Neurology 13:624, 1998

Dr. Rohith G. R., Junior Resident

Dr. Pramod Setty J., Prof. and Head, Dept. of Radio - Diagnosis.

"What medicines do not heal, the lance will ; what the lance does not heal, fire will" -Hippocrates

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