Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Arundhathi. S
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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2011 | Month : June | Volume : 5 | Issue : 3 | Page : 621 - 624

Carcinosarcoma of the Pancreas – Report of a case with a concise review of the literature


Department of Medical Oncology, Dept. of Pathology of Cancer Institute and Dept. of Gastrosurgery, Digestive Diseases Institute of Amrita Institute of Medical Sciences, Kochi, India.,

Correspondence Address :
Palaniappan M
Clinical Lecturer, Dept. of Medical Oncology,
Cancer Institute, Amrita Institute of Medical Sciences,
AIMS Ponekkara post, Edappally,
Kochi – 682041, Kerala, India.
Phone: 91-90485-48765


Carcinosarcomas are rare, mixed, malignant neoplasms which are composed of both carcinomatous and sarcomatous elements, showing distinct immunohistochemical and ultra structural features. While the uterus is one organ where they are encountered most often, some cases have been diagnosed in other organs, including the pancreas. We have reported a case of pancreatic carcinosarcoma which was diagnosed in our institute and have reviewed the epidemiology and the clinico-pathological characteristics of all cases of carcinosarcoma of the pancreas which have been reported worldwide.


Carcinosarcoma, Pancreatic cancer, Pancreaticoduodenectomy, Adenosquamous carcinoma, Leiomyosarcoma, Adjuvant chemotherapy

Carcinosarcoma is a rare, mixed, biphasic, malignant neoplasm which is composed of carcinomatous and sarcomatous elements, without areas of transition between them and with distinct immunohistochemical/ultra-structural features (1), (2). It occurs commonly in the female reproductive tract (most often in the uterus) as malignant, mixed, mullerian tumours. Although it is uncommon, it has also been occasionally described in other organs like the lung and breast and in parts of the gastrointestinal tract such as the gall bladder, the biliary tract, the liver, the pancreas, etc. (3).

Case summary
A 46-year-old male, a known type two diabetic and a dyslipidaemic on drugs, was referred to our center for further evaluation and management of cholestatic jaundice. Earlier he was evaluated outside for dyspeptic symptoms and jaundice of two weeks duration. At the initial visit, there were no significant clinical features, except for deep jaundice and mild itching all over the body. The routine blood tests showed a total bilirubin level of 13.6 mg/ dL, transaminase levels of 87 IU/L and 233 IU/L and an alkaline phosphatase level of 319 IU/L. CA19-9 was raised (252 U/ml). Computerized tomogram (Table/Fig 1) showed a hypo dense, oval lesion of size 3.4 x 3.4 x 1.5 cm in the head and in the uncinate process of pancreas, encasing the distal common bile duct (CBD) and causing moderate intra-hepatic biliary radical dilatation in both the lobes of the liver. Both the CBD and the proximal pancreatic duct were dilated and prominent.

After the metastatic work-up turned out to be negative, the patient was taken up for elective laparotomy. On the table, the surgeons found a mass of size 4 x 4 cm in the lower part of the head of the pancreas, with its medial border abutting but not infiltrating the superior mesenteric vessels. The liver and the peritoneum were free of the infiltration and there was no ascites. Though the peri-pancreatic planes were clear, significant lymph nodes were found in the retro-pancreatic area and near the roots of the right gastro-epiploic artery and the superior mesenteric artery. Pancreatoduodenectomy was performed. The histopathologicalreport of the surgical specimen was carcinosarcoma of the head of the pancreas (pT3N0M0). We treated him with Gemcitabine (1 gm/sqm on days one and eight of each three weekly cycle x six cycles) adjuvantly. He is on regular follow-up now at 28 months since diagnosis.

Gross and microscopic findings
The gross pathology revealed an ill-defined mass of size 3 x 3 x 2 cm, located in the inferior aspect of the head of the pancreas. The serial cut sections of the tumour showed a bright yellow to pale green mucoid surface, with areas of necrosis. The cut section of the CBD appeared uninvolved as like those of the stomach, the duodenum and the gall bladder. Five peri-pancreatic lymph nodes and a hepatic artery node were also submitted.The routine H and E staining of the sections of the pancreatic mass exhibited cells that were arrangedin glandular, focal papillary and cord patterns. The cells were pleomorphic with scanty to moderate cytoplasm, pleomorphic nuclei, prominent nucleoli and frequent mitoses. Focal mucin production and squamoid differentiation were seen. In addition, perineural invasion and lymphovascular emboli were noted. The stroma showed focal chrondroid areas as well as spindle shaped cells with pleomorphism and giant cell transformation. Some occasional bizarre cells with increased mitotic rate were also observed. The tumour had infiltrated the adjacent duodenal wall up to its sub-mucosal layer, while the resected margins were negative on all the sides. All the five peripancreatic lymph nodes and the hepatic artery node showed sinus histiocytosis. On running a battery of immunohistochemical markers (Table/Fig 2), (Table/Fig 3)(Table/Fig 4)(Table/Fig 5) the areas with the glandular, focal papillary and cord patterns showed positivity for cytokeratin and negativity for all other antibodies. The stromal areas tested positively for vimentin and SMA, negatively for cytokeratin, S-100 and desmin, and non-specifically for CD68 and alpha-1-antitrypsin. Both the areas had a high Ki67 index.


A thorough search of the PubMed literature showed only thirteen cases (including ours) of pancreatic carcinosarcoma to date, from various parts of the world (Table/Fig 6). Though it is premature to say as yet, with scanty number of cases in hand, it was seen that carcinosarcoma of the pancreas had a gender predilection towards females (69% females against 31% males). The mean age of the patients was 65 years and the median age was 67 years, with a range of ages from 46 to 90 years. The disease has been diagnosed most often in patients in their seventh decade of life.

Clinical features
The clinical features of carcinosarcoma of the pancreas are similar to that of the conventional one. From Table 2, it is obvious that pain in the epigastrium and/or in the right upper quadrant is the most common presenting complaint. The duodenum was the most commonly infiltrated local organ. Peri-pancreatic nodal infiltration, gastric infiltration, invasion of the large vessels and involvement of the CBD and the peri-pancreatic adipose tissue, are some other extents of the loco-regional spread.

Pathological features
The carcinomatous component varies widely, depending upon the morphology, the character and the arrangement of its atypical cells. The most common histopathological type is adenocarcinoma.

Mucinous cystadenocarcinoma (5) is another variant where the atypical epithelial cells form gland-like structures, the lumen of which contains the secreted mucinous material. In one case (2), though the epithelial component was largely a mucinous cystic neoplasm with its lining epithelium showing a range of dysplasia from adenomatous to carcinoma-in-situ, it was classified as carcinosarcoma due tothe presence of focal invasive areas of infiltrating carcinoma (of the poorly differentiated and the squamous types). On the other hand, there was a similar kind of diversity in its sarcomatous counterpart also. Around 60% of the cases showed sarcoma of the spindle cell type. Recently, osteosarcoma was demonstrated by Japanese authors in a case of carcinosarcoma that was shown to arise from intraductal papillary-mucinous carcinoma (6)(7)(8)(9)(10)(11).

The pathogenesis of carcinosarcoma of the pancreas is not clearly understood, as of now. Some researchers have offered explanations like composition, combination and conversion theories (2). One group of authors put across the theory of organ-induced tumour differentiation, where they showed that the two components were monoclonal in nature and that only the other anatomical organswhich were present in their vicinity, like the duodenum, had influenced their lines of further differentiation (4).

Another theory suggested that the tumour originates as a single cell (monoclonal origin), which would then undergo subsequent diversion and differentiation into carcinomatous and sarcomatous portions. Van den Berg and his colleagues (12) who studied genetic alterations in three cases of pancreatic carcinosarcoma, supported this theory. In another case which was reported recently (6), it is concluded that the well-differentiated adenocarcinoma had gradually enlarged in size, with some of its areas accumulating genetic alterations and subsequently transforming into rapidly growing segments of undifferentiated sarcomatous cells.

Management, prognosis and survival
Almost all the cases have been primarily treated by surgical therapy, the standard of which is pancreaticoduodenectomy. Scanty information is available about chemotherapy and radiotherapy in the management of this rare tumour. Gelos M and his colleagues treated their patient with six cycles of Gemcitabine following radical pancreaticoduodenectomy and achieved a survival period of 11 months (8). Gemcitabine delays disease progression when given adjuvantly to a patient with pancreatic cancer, who has undergone curative-intent surgery (13). From Table 2, it is obvious that the prognosis of carcinosarcoma of the pancreas is very poor, irrespective of any kind of treatment, with most of the patients having died within one year of diagnosis. Only three patients (including ours) are alive at the time of reporting of this case, with a mean survival period of 16 months among them.

Key Message

It is a rare malignancy of the exocrine pancreas.


Darvishian F, Sullivan J, Teichberg S, et al. Carcinosarcoma of the pancreas: a case report and review of the literature. Arch Pathol Lab Med 2002; 126:1114-1117.
Bloomston M, Chanona-Vilchis J, Ellison EC, et al. Carcinosarcoma of the pancreas arising in a mucinous cystic neoplasm. Am Surg 2006; 72:351-355.
Weidner N, Zekan P. Carcinosarcoma of the colon. Report of a unique case with light and immunohistochemical studies. Cancer 1986; 58:1126-1130.
Millis JM, Chang B, Zinner MJ, et al. Malignant mixed tumor (carcinosarcoma) of the pancreas: a case report supporting organinduced differentiation of malignancy. Surgery 1994; 115:132-137.
Wenig BM, Albores-Saavedra J, Buetow PC, et al. Pancreatic mucinous cystic neoplasm with sarcomatous stroma: a report of three cases. Am J Surg Pathol 1997; 21:70-80.
Yamazaki K. A unique pancreatic ductal adenocarcinoma with carcinosarcomatous histology, immunohistochemical distribution of hCG-beta, and the elevation of serum alpha-feto-protein. J Submicrosc Cytol Pathol 2003; 35:343-349.
Barkatullah SA, Deziel DJ, Jakate SM, et al. Pancreatic carcinosarcoma with unique triphasic histological pattern. Pancreas 2005; 31:291-292.
Gelos M, Behringer D, Philippou S, et al. Pancreatic carcinosarcoma. Case report of multimodal therapy and review of the literature. JOP 2008; 9:50-55.
Nakano T, Sonobe H, Usui T, et al. Immunohistochemistry and K-ras sequence of pancreatic carcinosarcoma. Pathol Int 2008; 58:672-677.
Shen ZL, Wang S, Ye YJ, et al. Carcinosarcoma of pancreas with liver metastasis combined with gastrointestinal stromal tumour of the stomach: is there a good prognosis with the complete resection? Eur J Cancer Care (Engl) 2010; 19:118-123.
Okamura J, Sekine S, Nara S, et al. Intraductal carcinosarcoma with a heterologous mesenchymal component originating in intraductal papillary-mucinous carcinoma (IPMC) of the pancreas with both carcinoma and osteosarcoma cells arising from IPMC cells. J Clin Pathol 2010; 63:266-269.
Van den Berg W, Tascilar M, Offerhaus GJ, et al. Pancreatic mucinous cystic neoplasms with sarcomatous stroma: molecular evidence for monoclonal origin with subsequent divergence of the epithelial and sarcomatous components. Mod Pathol 2000; 13:86-91.
Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 2007; 297:267-277.

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