Axillary reverse mapping: Is it feasible in locally advanced breast cancer patients?

INTRODUCTION: Axillary dissection is associated with a high incidence of lymphedema, which has been brought down with the introduction of sentinel lymph node biopsy (SLNB) in patients with early breast cancer. However, sentinel lymph node biopsy is not widely accepted in patients of locally advanced breast cancer (LABC) [T3N1, Any T4, Any N2-3 with no distant metastasis] after neo-adjuvant chemotherapy (NACT) and these patients routinely undergo axillary lymph node clearance. Axillary reverse mapping (ARM) with blue dye has the potential to differentiate the arm lymphatics from the breast lymphatics and it can be used to decrease lymphedema in patients undergoing ALND by preserving these lymphatics. However, ARM in LABC patients is yet to be accepted as the standard of care. MATERIALS AND METHODS: 51 patients of locally advanced breast carcinoma were included in the study from May 2011 to May 2012. All patients received neo-adjuvant chemotherapy followed by modified radical mastectomy. Axillary reverse mapping (ARM) was carried out using blue dye. 2 ml of methylene blue dye was injected intradermal, upper medial aspect of the ipsilateral arm. The number, size and site and distribution of lymph nodes identified were recorded and the nodes were labelled as ARM nodes and complete axillary dissection was carried out. RESULTS: Blue nodes were identified in 45 (88.2%) out of the 51 patients. The average number of ARM nodes identified was 4.03 ± 0.28 [range 1-8]. In majority (77.8%) of the cases, nodes were located in the triangle formed by axillary vein above, below by the first intercostobrachial nerve and medially by the chest wall/serratus anterior. In patients with complete or partial response to NACT, ARM and breast axillary LN were negative in 63.3% patients whereas 36.6% had positive breast but negative ARM nodes. In this study we did not intend to preserve any ARM nodes but in 90% of these cases, at least one ARM node had to be removed or was injured during axillary clearance. ARM nodes could be identified in 15 (83.3%) out of the 18 patients with stable or progressive disease following ARM. 12 (80%) out of these 15 cases demonstrated positive ARM and breast LN whereas 3 (20%) patients had positive breast but negative ARM nodes. Skin tattooing (82.3%) was the most common complication observed in our study. CONCLUSIONS: Identification rates of ARM nodes can be improved by injecting the blue dye in the upper medial aspect of the arm at the time of induction. Majority of the arm nodes lie between the axillary vein and the first intercostobrachial nerve. It is difficult to preserve the ARM nodes in patients of LABC, who have had good response to NACT and in patients of LABC with poor response to NACT, the incidence of metastasis in ARM nodes is quite high. Therefore, ARM is not a feasible option in patients with locally advanced breast cancer.

Poland's syndrome: a case report with review of literature regarding management.

BACKGROUND: Poland's syndrome is a rare congenital anomaly described by Alfred Poland in 1897 which is characterize by partial or complete absence of the pectoralis major muscle, ipsilateral symbrachydaktylia and occasionally associated with other malformations of the anterior chest wall and breast. The incidence of Poland's syndrome is 1: 30,000 and it is more commonly seen in males. CASE DESCRIPTION: A 22-year-old female presented with a history of chest wall depression and a small sized left breast. On examination she had unilateral hypoplasia of the left breast, absence of the anterior axillary fold and hypoplastic pectoralis major and minor muscle with mild pectus excavatum. The patient's breast was reconstructed with an autologous anterolateral thigh (ALT) perforator flap after using an expander. DISCUSSION: This case illustrates the potential benefit of utilizing autologous ALT perforator flap in a girl with Poland's syndrome with a deformed chest wall with hypoplasia of pectoral muscles and absence of the anterior axillary fold which makes positioning of an implant difficult. Breast reconstruction using a microvasular perforator flap is an alternative method to restore the contour of the chest and breast without the use of an implant.

Idiopathic granulomatous mastitis: a rare entity with a variable presentation.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a rare, chronic benign breast disease which may mimic a breast abscess or malignancy. It is a diagnosis of exclusion, and requires a high index of suspicion. Most patients present in the third or fourth decade of life. CASE SERIES: We present a case series of IGM with varied presentation, as a non-resolving abscess and as a lump, clinically appearing to be malignant. Patients required repeated drainage and/or lumpectomy. CONCLUSION: Although IGM is considered to be autoimmune in aetiology, however other infectious aetiologies causing granulomatous mastitis and malignancy have to be ruled out by histopathology. In the event of relapse immunosuppression may be required.

Breast cancer presenting in the midline without a lesion in the breast: a therapeutic dilemma.

Breast cancer presenting in the midline of the chest and without a primary focus in the breast is extremely rare. A 48 year old post-menopausal lady presented with a rapidly enlarging lump over the middle of her chest along with bilateral axillary lymph nodes. Clinical and imaging tests failed to demonstrate a focus of cancer in either of the breasts. Incisional biopsy of the lesion revealed it to be an infiltrating ductal carcinoma. As no guidelines exist to manage such patients, she was started on neo-adjuvant chemotherapy. Following a good response to chemotherapy, she underwent wide local excision of the lesion with bilateral axillary lymphadenopathy. She subsequently received adjuvant chemotherapy, radiotherapy and hormonal therapy.

Breast tuberculosis mimicking a malignancy: a rare case report with review of literature.

Breast tuberculosis an uncommon form of tuberculosis and it usually presents as a lump in the breast. Tuberculosis of the breast can masquerade many breast diseases including malignancy and idiopathic granulomatous mastitis. The varied presentation poses a diagnostic and therapeutic dilemma for the clinicians. We report a case of a 56 year old lady who presented with a lump in the breast and overlying skin ulceration, which resembled a malignancy on clinical examination and radiological investigations. Histo-pathology confirmed the diagnosis of tuberculosis and the patient responded to anti tubercular drugs.

Buccal metastasis in a case of carcinoma breast: A rare case report with review of literature.

INTRODUCTION: Metastatic lesions to oral cavity from distant tumours account for 1% of all oral cavity malignancies. Oral cavity is a rare site of metastasis from the breast. We describe case report of breast cancer patient with metastasis to buccal mucosa. PRESENTATION OF CASE: We report a case of pre-menopausal woman with left side infiltrating ductal carcinoma breast - T4aN1M0. She received three cycles of neo-adjuvant chemotherapy followed by modified radical mastectomy (MRM) and three cycles of adjuvant chemotherapy and loco-regional EBRT. She presented with a lump in region of MRM scar and a painful swelling in the right cheek, one year afterwards. Core needle biopsy from scar site revealed infiltrating ductal carcinoma. CECT revealed a heterogeneous lesion (1.1cm×1.7cm) in right masticator space, which on biopsy revealed metastatic deposit consistent with infiltrating ductal carcinoma. DISCUSSION: Metastatic lesions to oral cavity from distant tumours are uncommon. They mainly involve bony structures. Primary metastases to soft tissues are rare and accounts for 0.1% of oral malignancies. In our case, patient presented with scar recurrence and distant metastasis at an unusual site. Had it not been for scar recurrence, patient might not have presented to the OPD with oral swelling. A high degree of clinical suspicion and previous history of breast cancer led to detection of metastatic deposit. CONCLUSION: Diagnosis of a metastatic lesion in buccal mucosa is challenging and requires a high degree of clinical suspicion.

Current Debates in Surgery - A Cross Sectional Study amongst Indian Surgeons.

Surgery like all fields of medicine is evolving rapidly and these new techniques are challenging to replace the existing 'standard of care'. Though some of these advances are here to stay, many of them are driven by a handful of surgeons influenced by market forces. In some controversial topics, there is a problem of plenty and it is difficult for a general surgeon to choose from the various options available. In order to address some of these contentious issues, a cross sectional, questionnaire based study was designed. The questionnaire was posted to surgeons across the country and it included 11 questions (single best answer format) on the current debates in surgery. The questionnaire was answered by 778 surgeons and gave rise to interesting observations. The practice of surgery is an interplay of patient- surgeon and market forces and more comprehensive studies are required to address these controversial topics in surgery.

Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study.

OBJECTIVES: To find out factors that are responsible for the patient or provider delays in the diagnosis of breast cancer in India. DESIGN: This prospective study was designed to be conducted over a period of two years including a cohort of 100 patients with locally advanced breast cancer. The delays were assessed using questionnaires prepared according to the Indian scenario. SETTING: A prospective study in an Indian setting. PARTICIPANTS: One hundred patients with locally advanced breast cancer receiving neoadjuvant chemotherapy were included after providing informed consent and receiving ethical committee clearance. MAIN OUTCOME MEASURES: The most common factor responsible for delays in diagnosis was observed to be the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease. RESULTS: One hundred patients of locally advanced breast cancer were evaluated using standardized questionnaires to assess the delays in diagnosis. Provider delays were found to be significant (the unregistered doctors or quacks being a significant cause of delays).The average time lapse before diagnosis for rural patients was higher (67.5 days) compared to urban patients (53.7 days). The literacy levels of the patients also had a significant impact on the delays at diagnosis. The delay in illiterates was 60.6 days compared to 49.5 days for literates. CONCLUSIONS: The most common factor responsible for delays in reporting and diagnosis was observed to be at the end of the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease.

Duplication of vas deferens-A rare anomaly with review of literature.

INTRODUCTION: Isolated duplication of vas deferens is a rare anomaly with only eleven cases reported in medical literature. Unawareness regarding this rare anomaly can lead to inadvertent injury to the vas during inguinal hernia surgery or failure of vasectomy procedure. PRESENTATION OF CASE: A 27-year-old gentleman was diagnosed with isolated duplication of vas during left sided open inguinal hernia surgery. He had no other genito-urinary anomaly. Patient had an uneventful recovery from surgery. CONCLUSION: It is a rare anomaly and unawareness regarding this condition can lead to catastrophic consequences during inguinal hernia and vasectomy surgeries.

The correlation of anxiety and depression levels with response to neoadjuvant chemotherapy in patients with breast cancer.

BACKGROUND: The aim was to evaluate and correlate anxiety and depression levels with response to neoadjuvant chemotherapy in patients with breast cancer. The study also assessed the effects of family support on distress levels. DESIGN: It was a prospective study in a cohort of 84 patients with locally advanced breast cancer. These assessments were done using the Hospital Anxiety and Depression Scale (HADS). SETTING: A prospective study in a developing world setting. PARTICIPANTS: Eighty-four patients with locally advanced breast cancer receiving neoadjuvant chemotherapy were included after taking an informed consent and ethical committee clearance. MAIN OUTCOME MEASURES: A significant correlation was observed between response to neoadjuvant chemotherapy and depression levels in breast cancer patients. Joint family and literacy levels also had an impact on the levels of depression observed. RESULTS: A total of 84 patients receiving neoadjuvant chemotherapy for breast cancer were evaluated using HADS. The effect of family support, literacy levels and employment on the psychological status of these patients were also assessed. CONCLUSIONS: The response to neoadjuvant chemotherapy had a direct correlation with the levels of depression, the distress levels being lower in responders. This was found to be the most important variable determining the psychological status of the patients. It was also observed that Indian patients in comparison to their Western counterparts react differently to cancer-related stress.

Vulval elephantiasis as a result of tubercular lymphadenitis: two case reports and a review of the literature.

INTRODUCTION: Elephantiasis as a result of chronic lymphedema is characterized by gross enlargement of the arms, legs or genitalia, and occurs due to a variety of obstructive diseases of the lymphatic system. Genital elephantiasis usually follows common filariasis and lymphogranuloma venereum. It may follow granuloma inguinale, carcinomas, lymph node dissection or irradiation and tuberculosis but this happens rarely. Vulval elephantiasis as a consequence of extensive lymph node destruction by tuberculosis is very rare. We present two very unusual cases of vulval elephantiasis due to tuberculous destruction of the inguinal lymph nodes. CASE PRESENTATION: Two Indian women - one aged 40 years and the other aged 27 years, with progressively increasing vulval swellings over a period of five and four years respectively - presented to our hospital. In both cases, there was a significant history on presentation. Both women had previously taken a complete course of anti-tubercular treatment for generalized lymphadenopathy. The vulval swellings were extremely large: in the first case report, measuring 35 × 25 cm on the right side and 45 × 30 cm on the left side, weighing 20 lb and 16 lb respectively. Both cases were managed by surgical excision with reconstruction and the outcome was positive. Satisfactory results have been maintained during a follow-up period of six years in both cases. CONCLUSIONS: Elephantiasis of the female genitalia is unusual and it has rarely been reported following tuberculosis. We report two cases of vulval elephantiasis as a consequence of extensive lymph node destruction by tuberculosis, in order to highlight this very rare clinical scenario.

Isolated unilateral duplication of vas deferens, a surgical enigma: a case report and review of the literature.

BACKGROUND: Duplication of vas deferens is a very rare congenital anomaly with only a few cases reported in the literature. Injury to vas deferens is a recognized complication during hernia surgery and the possibilities of injury may increase with lack of awareness of this anomaly. CASE REPORT: A-31-year old gentleman with unilateral duplication of vas deferens that was diagnosed during right sided open hernia surgery is reported. The patient had undergone surgery for left inguinal hernia one year previously at the same center and no such anomaly was detected. During intra-operative examination of scrotum, the testes and epididymis were found to be normal. Patient had an uneventful recovery from hernia surgery. CONCLUSION: Unilateral duplication of vas deferens is rare. The identification of this anomaly is essential in order to minimize the incidence of injury to vas during hernia surgery. This case reinforces the importance of routine identification of vas deferens and awareness about this anomaly during inguinal hernia surgery.

'Frozen finger' in anal fissures.

Acute anal fissures are usually managed by various invasive and non-invasive modalities ranging from simple lifestyle changes to chemical and surgical sphincterotomies. Frozen finger, prepared using a water-filled ordinary rubber glove, was successfully used in one hundred patients, thus providing a cost-effective and simple solution to the problem.

Carcinoma developing in a fibroadenoma in a woman with a family history of breast cancer: a case report and review of literature.

INTRODUCTION: Malignant transformation of a fibroadenoma is rare with only about 100 cases reported in the world literature. Fibroadenoma occurring in middle aged woman with a strong family history of breast or ovarian cancer should be investigated with a high suspicion for malignancy. CASE PRESENTATION: A 35-year- old Indian lady operated previously for fibroadenoma of the right breast presented with a recurrent lump at the same site. She had a strong family history of breast carcinoma. Mammography and trucut biopsy was suggestive of infiltrating duct carcinoma. She was managed by lumpectomy and axillary lymph node dissection with a satisfactory outcome. There was no evidence of BRCA-1, BRCA-2 mutation on immunohistochemistry. CONCLUSION: Malignant change in a pre-existing fibroadenoma is rare, however in a middle aged woman with a family history of breast cancer it should be suspected. In the absence of any definite clinical and radiological criteria of diagnosing malignant change in a fibroadenoma, high suspicion index is mandatory. The management and outcome depends on the stage and grade of presentation.

Qualitative and quantitative dermatoglyphic traits in patients with breast cancer: a prospective clinical study.

BACKGROUND: Breast cancer is one of the most extensively studied cancers and its genetic basis is well established. Dermatoglyphic traits are formed under genetic control early in development but may be affected by environmental factors during first trimester of pregnancy. They however do not change significantly thereafter, thus maintaining stability not greatly affected by age. These patterns may represent the genetic make up of an individual and therefore his/her predisposition to certain diseases. Patterns of dermatoglyphics have been studied in various congenital disorders like Down's syndrome and Kleinfelter syndrome. The prints can thus represent a non-invasive anatomical marker of breast cancer risk and thus facilitate early detection and treatment. METHODS: The study was conducted on 60 histo-pathologically confirmed breast cancer patients and their digital dermatoglyphic patterns were studied to assess their association with the type and onset of breast cancer. Simultaneously 60 age-matched controls were also selected that had no self or familial history of a diagnosed breast cancer and the observations were recorded. The differences of qualitative (dermatoglyphic patterns) data were tested for their significance using the chi-square test, and for quantitative (ridge counts and pattern intensity index) data using the t- test. RESULTS: It was observed that six or more whorls in the finger print pattern were statistically significant among the cancer patients as compared to controls. It was also seen that whorls in the right ring finger and right little finger were found increased among the cases as compared to controls. The differences between mean pattern intensity index of cases and controls were found to be statistically significant. CONCLUSION: The dermatoglyphic patterns may be utilized effectively to study the genetic basis of breast cancer and may also serve as a screening tool in the high-risk population. In a developing country like India it might prove to be an anatomical, non-invasive, inexpensive and effective tool for screening and studying the patterns in the high-risk population.