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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
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
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
High Grade Dysplastic Villous Adenoma Arising from a Giant Hamartomatous Polyp- A Rare Case Presentation
Correspondence Address :
Dr. J Thanka,
Professor, Department of Pathology, Sree Balaji Medical College and Hospital, Chennai-600044, Tamil Nadu, India.
E-mail: thanka7paul@gmail.com
Adenomatous polyps can be found throughout the colon, most commonly in right colon. Microscopically, they are classified as tubular, villous or tubulovillous subtypes. Tubular adenomas are the most common subtype with villous component less than 25%. Tubulovillous adenomas have a villous component that accounts for 25-75%, while villous adenomas have a villous component, that accounts for more than 75% of the polyp. Peutz-Jeghers syndrome which is an autosomal dominant condition is characterised by gastrointestinal hamartomatous polyp with distinctive arborisation of smooth muscle within the lamina propria. Peutz-Jeghers type polyp is a hamartomatous polyp without associated mucocutaneous pigmentation or a family history of Peutz-Jeghers syndrome. In the present case study, a 82-year-old male presented with the chief complaint of constipation and abdominal distension since six months. A polypoidal rectal growth was identified on sigmoidoscopy. The clinical diagnosis of mid-rectal growth with acute colonic obstruction was made. Positron Emission Tomography and Computed Tomography (PET CT) was done which was suggestive of malignancy and therefore, Hartmann’s procedure was performed and lesion was excised. On gross examination, a portion of large intestine including sigmoid colon and rectum was received and a pedunculated polypoidal lesion measuring 4.5×3.5×3 cm along with stalk measuring 2.5 cm was seen. On microscopy, the polyp with extensive arborisation of muscularis mucosa into the lamina propria was seen with one area showing features of villous adenoma with high-grade dysplasia. Hence, a final diagnosis was given as villous adenoma with high grade dysplasia arising from a hamartomatous polyp consistent with Peutz-Jeghers polyp. The identification of a villous adenoma with high-grade dysplasia in a Peutz-Jeghers type polyp is essential in such situations, since it is a precursor of invasive malignancy.
Arborisation, Christmas tree pattern, Giant polyp, Hartmann’s procedure, Peutz-Jeghers polyp
An 82-year-old male presented to Surgical Gastroenterology Department with the chief complaint of constipation and abdominal distension since six months. He was a known case of hypertension since 20 years and Parkinsonism since 12 years and was on treatment. On physical examination, abdomen was soft, not tender and bowel sounds were heard. Power in bilateral lower limbs was reduced. On sigmoidoscopy, a polypoidal rectal growth was identified and a provisional diagnosis of mid rectal growth with acute colonic obstruction was made. Positron Emission Tomography and Computed Tomography (PET CT) was done and an intensely hypermetabolic, eccentric mural thickening measuring 5.8×2.9 cm in the sigmoid colonwas seen, suggestive of primary malignancy of distal sigmoid colon. No other significant lab findings were seen. Hartmann’s procedure was performed by the Surgical Gastroenterology Team.
A segment of resected sigmoid colon and rectum was received in the pathology laboratory. On gross examination, a pedunculated, polypoidal lesion located in the mid-rectum was seen, involving almost the whole circumference, 21 cm from the proximal resected margin and 4 cm from distal resected margin. It measured 4.5×3.5×3 cm with stalk measuring 2.5 cm (Table/Fig 1).
No evidence of infiltrating firm or hard areas was seen and the rest of the mucosa appeared to be normal. Multiple sections were taken from the specimen and the histopathological examination showed a large pedunculated polyp showing extensive arborisation of muscularis mucosa into the lamina propria indicating a hamartomatous polyp showing a characteristic christmas tree appearance (Table/Fig 2). Focal glands in the polyp showed serrations and mucosa lining the stalk of the polyp appeared normal. This hamartomatous polyp has a component of villous adenoma with high-grade dysplasia showing nuclear enlargement, pleomorphism, hyperchromasia, enlarged nucleoli, loss of polarity and loss of goblet cell mucin (Table/Fig 3),(Table/Fig 4). However, there was no evidence of invasive malignancy in any of the sections examined. The resected margins and the rest of the colon were free from tumour. One lymph node was also identified, that showed only reactive changes and was negative for malignancy.
Based on the above findings, as per World Health Organisation (WHO) classification of tumours fifth edition-Digestive System Tumours (1), the final impression of villous adenoma with high-grade dysplasia arising from a hamartomatous polyp consistent with solitary Peutz-Jeghers type was made. The patient recovered fully after surgery but later developed acute myocardial infarction on the day of discharge and succumbed to death.
Adenomatous polyps can be found throughout the colon, most commonly in the right colon. They have an increasing incidence with age so that at the age of 60 years, they are found in about 20% of the population (2). However, not all adenomas are polyps. Flat adenomas are defined as adenomas whose height is less than twice the thickness of the adjacent normal mucosa, and are increasingly recognised as an alternative precursor lesion of colorectal carcinomas (2).
There are two main histological types:tubular (75%) and villous (10%); the remaining 15% are intermediate in pattern and are designated tubulovillous (3). Large size, villous content and distal location are all associated with severe dysplasia in colorectal adenomas (4). Villous adenomas are more frequently sessile and larger. They are often over 20 mm in diameter and some extend over a wide area as a thick, carpet-like growth. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection (5).
Microscopically, they consist of elongated villi in a papillary growth pattern. The villi are lined by columnar epithelium showing dysplasia.Tubulovillous adenomas have a villous architecture that comprises of 25% or more of the polyp, while villous adenomas have a villous component that accounts for 75% or more of the polyp (6).
Conventional adenomas are graded into two tiered classification as low-grade and high grade dysplasia. Features of high-grade dysplasia include marked complex glandular crowding, irregularity of glands, cribriform architecture and intraluminal necrosis along with loss of polarity, marked enlarged nuclei with prominent nucleoli, a dispersed chromatin pattern with frequent atypical mitosis.
Giant polyps are usually defined as more than 3 cm on endoscopy (7). There is less than a 5% incidence of carcinoma in an adenomatous polyp less than 1 cm in size, whereas there is a 50% chance that a villous adenoma greater than 2 cm in size will contain cancer (8). Bains L et al., reviewed a total of 25 giant villous tumours from 2001 to 2018, with size range 5-31 cm, which showed carcinoma (including invasive) in eight, high-grade dysplasia in six, low to moderate-grade dysplasia in six, whereas rest negative for malignancy. It puts the risk of dysplasia to about 50 % and malignancy in 33 % of cases of giant rectal villous adenomas (5).
Hamartomatous polyps are composed of the normal cellular elements of the gastrointestinal tract, but have a markedly distorted architecture. The autosomal dominant disorder Peutz-Jeghers Syndrome (PJS) is characterised by presence of hamartomatous polyps in the gastrointestinal tract. The Peutz-Jeghers syndrome is brought on by a germline mutation in the serine threonine kinase/liver kinase B1 gene (STK11, formerly known as LKB1) on human chromosome 19p13. More than 70% of the familial cases show STK11 mutation. In Peutz-Jeghers syndrome patients, loss of heterozygosity is found in 25-38 percent of colonic polyps and 64-100% of adenocarcinomas, respectively. Recent animal investigations, however, have revealed that biallelic deletion of STK11 is not required for polyp development (9).
Polyps are practically always seen as part of a Peutz-Jeghers syndrome and have microscopic features similar to their more common counterparts in the small bowel (6). Histologically, Peutz-Jeghers polyps can be identified by their distinctive smooth muscle arborisation in the lamina propria. Peutz-Jeghers polyps of the colon can look like mucosal prolapse polyps or any other colonic polyp that prolapses. Lack of cellular atypia, disorganisation of glands, the occurrence of several cell types (including Paneth cells), and the presence of smooth muscle fibers from the muscularis mucosae (which give the lesion a “hamartomatous” appearance). This pattern of glandular disorganisation and epithelial misplacement, simulating invasion should not be confused with malignancy (10).
Most commonly the patients of Peutz-Jeghers syndrome present usually in the first three decades of life, but this patient was an elderly male. Clinically, they mostly present with the complaints of intestinal obstruction, abdominal pain, blood in the stool and anal extrusion of polyp. Rarely they are also diagnosed by prominent mucocutaneous melanin pigmentation (11). Most commonly the lesions are found in the small bowel, however other sites of presentation are: colon, stomoach and rectum. In patient in the present case, it presented as a rectal lesion.
There are many theories behind the pathophysiology of the hamartoma adenoma carcinoma cascade in PJS. Several studies have explained, how second hit mechanism of LKB1 causes loss of heterozygosity (LOH) in adenomatous lesions and carcinomas in PJS polyps. A hamartomatous polyp without associated mucocutaneous pigmentation or a family history of Peutz-Jeghers syndrome is diagnosed as a solitary Peutz-Jeghers type hamartomatous polyp (12). The incidence of solitary Peutz-Jeghers type polyps is extremely low (13). The solitary Peutz-Jeghers type polyp can be found in the gastrointestinal tract; more cases occur in the small intestine, followed by colorectal region. The solitary gastric Peutz-Jeghers type polyps are the rarest.
Burkart AL et al., reviewed all reported cases of solitary Peutz-Jeghers type polyps in the hospital in 22 years and concluded that solitary Peutz-Jeghers-type polyps are extremely rare, they are also associated with the risk of cancer similar to PJS, and they may be incomplete PJS. Eight cases with malignant components were found in the Peutz-Jeghers type polyp (14). The adenomatous transformation seen in hamartomatous polyps also had B-catenin and K-Ras mutations and LOH of p53. This suggests that mutations in these genes can also lead to carcinogenesis in PJS polyps (15). In patient in the present case, there is villous adenomatous transformation with high grade dysplasia which is very rare.
It has been suggested that, mucosal prolapse plays a role in the pathophysiology of the distinctive hamartomatous polyps in PJS. There is no such thing as a hamartoma adenoma carcinoma sequence, according to this theory, and PJS polyps are a precancerous state. STK11/LKB1 is a tumour suppressor gene that regulates cellular polarity and intracellular signalling. The importance of LKB1 in cellular polarity and the loss of polarity function in PJS may impact asymmetric stem cell division and result in the enlargement of the stem cell pool. It could cause polyp growth as well as raise the risk of cancer. Mesenchymal cells which were STK11-deficient produced less TGF and had faulty TGF signalling to epithelial cells, according to a recent study, which correlated with epithelial proliferation. This explains, why tumour suppression mechanisms derived from the stroma are also important in PJS (16).
Laparotomy and bowel resection have been the primary treatment for PJS for many years to remove symptomatic gastrointestinal polyps. Several different syndromes have been described with the propensity to develop hamartomatous polyps in the upper and lower gastrointestinal tracts. These include juvenile polyposis, Peutz-Jeghers syndrome, hereditary mixed polyposis syndrome, and the PTEN hamartoma tumour syndromes (Cowden and Bannayan- Riley-Ruvalcaba syndromes), which are autosomal-dominantly inherited, and Cronkhite-Canada syndrome, which is acquired (17). Solitary Peutz-Jeghers type polyp is itself a rare entity. Adenomatous transformation in a Peutz-Jeghers type polyp is even rarer. In the PubMed database, the terms “Solitary Peutz-Jeghers type polyp” yielded 81 cases around the world. The terms Peutz-Jeghers and giant polyp gave seven case studies. Adenomatous transformation of the Peutz-Jeghers type polyp was seen in only seven cases (12),(18),(19). Limaiem F et al., described a 27-year-old patient with solitary 15 cm sized hamartomatous Peutz-Jeghers type polyp in the lower rectum with features of adenoma (18). Sekino Y et al., 84-year-old Japanese man had hamartomatous polyp-branching bundles of smooth muscle fibers covered by hyperplastic duodenal mucosa with a focus of well-differentiated adenocarcinoma (12). Matsui T et al., presented a case of adult intussusception in the transverse colon with an advanced ileal Peutz-Jeghers type polyp associated with cancer (19).
The present exceedingly singular rare case of a villous adenoma with high grade dysplasia arising from a giant hamartomatous Peutz-Jeghers type polyp highlights the importance of vigilant histopathological examination. The need for careful and diligent assessment for detection of malignant pathology in a hamartomatous polyp is crucial, as it changes the treatment and prognosis of the patient.
DOI: 10.7860/JCDR/2022/59064.17338
Date of Submission: Jul 14, 2022
Date of Peer Review: Aug 17, 2022
Date of Acceptance: Oct 15, 2022
Date of Publishing: Dec 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 29, 2022
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