Ten-year survival outcome of breast cancer patients in India.

INTRODUCTION: Breast cancer is the most frequently diagnosed cancer among women in India; however, there are no studies addressing long-term survival (10 years and above). This study sought to evaluate long-term oncological outcome among women with breast cancer treated with a curative intent. MATERIALS AND METHODS: This is a retrospective cohort analysis of 1301 breast cancer patients of all stages who had received primary treatment with curative intent from 2004 to 2010 at a single cancer institution of India. RESULTS: A total of 1301 breast cancer patients were available for final analysis. The median age was 51 years (range, 21-86 years). 70.25% of the patients had early breast cancer (EBC), 21.9% had locally advanced breast cancer, and 7.85% of the patients with de novo metastatic disease also underwent surgery. 56.5% of the patients had hormone-sensitive tumors, human epidermal growth factor receptor 2 over expression was seen in 17%, and triple-negative tumors accounted for 26.2% of the patients. The 5- and 10-year overall survival (OS) of the entire cohort was 79% and 66%, and the 5- and 10-year breast cancer-specific survival (BCSS) was 79% and 70%, respectively. OS and BCSS were 51% and 58%, respectively, at 15-year follow-up after primary cancer treatment. On multivariate analysis, the factors associated with prolonged survival were age ≤50 years, EBC, and treatment during the later period (2008-2010). CONCLUSION: Difference between OS and BCSS was found to have an increasing trend during 10-15-year follow-up, the difference being 4% at 10 years and 7% at 15 years. Age ≤50 years, early-stage disease at presentation, and primary cancer treatment in later years (2008-2010) were favorable predictors for 10-year survival.

Expression of a novel endothelial marker, C-type lectin 14A, in epithelial ovarian cancer and its prognostic significance.

OBJECTIVE: The purpose of this study was to evaluate microvessel density (MVD) as assessed by C-type lectin 14A (CLEC14A), which is a new marker for endothelial cells, and compare its expression to CD31 and CD105 in epithelial ovarian cancer (EOC). METHODS: MVD was evaluated in tumors (n = 50) from patients with EOC who underwent primary surgery and in patients with EOC who received preoperative chemotherapy (n = 49) using immunohistochemistry with antibodies to CLEC14A, CD31 and CD105. The median duration of follow-up was 24.5 months (range 1-101 months). The effect of prognostic factors on event-free survival (EFS) and overall survival (OS) was assessed using the Cox regression model. RESULTS: The amount of residual disease was found to be an independent prognostic factor in multivariate analysis with respect to EFS (P = 0.009) and OS (P < 0.001). The mean MVD of CLEC14A (MVD = 6), in tumors from patients who underwent primary surgery, was significantly lower than that of CD31 (MVD = 25, P < 0.0001) and CD105 (MVD = 11, P = 0.018). However, there was no significant correlation between MVD as detected by these markers and clinical outcome. There was no expression of CLEC14A in tumors from patients who received preoperative chemotherapy and the MVD of CD31 and CD105 was significantly reduced (P = 0.001 and 0.006, respectively) in this set of patients. CONCLUSION: This study demonstrates MVD as detected by CLEC14A in EOC. Treatment with chemotherapy reduces tumor blood vessels significantly. We suggest that CLEC14A may be a more specific endothelial marker to assess tumor angiogenesis.

Delivery of affordable and equitable cancer care in India.

The delivery of affordable and equitable cancer care is one of India's greatest public health challenges. Public expenditure on cancer in India remains below US$10 per person (compared with more than US$100 per person in high-income countries), and overall public expenditure on health care is still only slightly above 1% of gross domestic product. Out-of-pocket payments, which account for more than three-quarters of cancer expenditures in India, are one of the greatest threats to patients and families, and a cancer diagnosis is increasingly responsible for catastrophic expenditures that negatively affect not only the patient but also the welfare and education of several generations of their family. We explore the complex nature of cancer care systems across India, from state to government levels, and address the crucial issues of infrastructure, manpower shortages, and the pressing need to develop cross-state solutions to prevention and early detection of cancer, in addition to governance of the largely unregulated private sector and the cost of new technologies and drugs. We discuss the role of public insurance schemes, the need to develop new political mandates and authority to set priorities, the necessity to greatly improve the quality of care, and the drive to understand and deliver cost-effective cancer care programmes.

Cancer research in India: national priorities, global results.

Over the past 20 years, cancer research in India has grown in size and impact. Clinicians, scientists, and government and state policy makers in India have championed cancer research, from studies to achieve low-tech, large-scale health outcomes to some of the most advanced areas of fundamental cancer science. In this paper, we frame public policy discussions about cancer with use of an in-depth analysis of research publications from India. Cancer research in India is a complex environment that needs to balance public policy across many competing agendas. We identify major needs across these environments such as those for increased research capacity and training and protected time for clinical researchers; for more support from states and enhanced collaborative funding programmes from government; for development of national infrastructures across a range of domains (ie, clinical trials, tissue banking, registries, etc); and for a streamlined and rational regulatory environment. We also discuss improvements that should be made to translate research into improvements in cancer outcomes and public health.

Impact of COVID-19 on the Diagnosis and Surgical Care of Patients with Breast Cancer-a Retrospective Observational Cohort Study from Kerala, South India.

The COVID-19 pandemic has strained the healthcare system worldwide. Our study aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis and surgical care of patients with breast cancer in Amrita Institute of Medical Sciences, Kochi. This is a single-centre retrospective observational cohort study conducted in a tertiary care institution intended to analyse the management of patients with breast cancer before and after the pandemic outbreak. The number of mammograms dropped from 3689 in the pre-pandemic phase to 1901 in the post-pandemic phase, whilst the number of core biopsies remained almost the same (391 before the pandemic and 367 after the pandemic). The number of new patients decreased by 57.7% (from 614 to 354). However, the number of breast cancer surgeries has remained almost the same (318 before the pandemic and 287 after the pandemic). The number of breast conservation surgeries dropped from 127 in 2019 to 93 in 2020 (p-value = 0.01). Conversely, 24 patients underwent neoadjuvant chemotherapy in 2019, and this number increased to 37 in 2020, representing a statistically significant increase (p = 0.04). Even during a pandemic, cancer care is possible with proper resource allocation and by adopting a multidisciplinary approach.

Ki 67: a Promising Prognostic Marker in Early Breast Cancer-a Review Article.

Ki67 index is considered to be a reliable indicator of the proliferative activity of breast cancer. Additionally, the Ki67 proliferative marker may play a role in assessing response to systemic therapeutic strategies and can act as a prognostic biomarker. But its limited reproducibility which stems from a lack of standardization of procedures, inter-observer variability, and preanalytical and analytical variabilities all have hampered the use of the Ki67 index in clinical practice. Currently, clinical trials have been evaluating Ki67 as a predictive marker for needing adjuvant chemotherapy in luminal early breast cancer patients receiving neoadjuvant endocrine therapy. But the inconsistencies existing in the estimation of the Ki67 index limit the utility of Ki67 in standard clinical practice. The purpose of this review is to evaluate the benefits and drawbacks of utilizing Ki-67 in early-stage breast cancer to prognosticate the disease and predict the risk of recurrence.

Unchartered waters: Significance of fall in Ki67 index after short-term preoperative endocrine therapy in early breast cancers.

BACKGROUND: Endocrine treatment for breast cancer acts largely by inhibiting tumor cell proliferation. The biomarker Ki67 is linked to the proliferative index of the tumour. OBJECTIVE: To identify the factors affecting the fall in Ki67 value in early-stage hormone receptor (HR) positive breast cancer patients receiving short-term preoperative endocrine therapy in an Indian cohort. METHODS: Women with hormone receptor positive, invasive, nonmetastatic, and early breast cancer (4 week) did not affect the fall in Ki67. CONCLUSION: Preoperative therapy with Letrozole resulted in a more significant fall in Ki67, as compared to therapy with Tamoxifen. Determining the fall in Ki67 value in response to preoperative endocrine therapy could provide an insight into the response to endocrine therapy in luminal breast cancer.

Pretreatment neutrophil-to-lymphocyte ratio predicts lymph node metastasis in triple-negative breast cancer.

Background: The purpose of the study was to investigate the value of pretreatment neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker in triple-negative breast cancer (TNBC) and to see its bearing on the clinical and pathological stage of the disease. Methods: This was a retrospective analysis of cases of TNBC treated at our center from 2006 to 2013. The pretreatment complete blood count was recorded from which the NLR was calculated as the percentage of neutrophils divided by the percentage of lymphocytes. The association between pretreatment NLR with the stage of the disease, clinical and pathological lymph node status, and disease-specific survival was analyzed. Results: A total of 208 patients were eligible for the analysis. The median follow-up period was 48 months. The NLR was found to have a strong correlation with the pathological nodal status and the clinical stage (75% cases node-positive in the high NLR group versus 36% in the low NLR group; P < 0.01). At the time of analysis, 74% of our study population was alive and well. There was no significant correlation between the NLR and the overall survival. Conclusions: Based on our study, we conclude that the pretreatment NLR is strongly associated with lymph node metastasis and clinical stage in TNBC patients. It is probably not useful as a prognostic marker, as it does not seem to have any significant bearing on the overall survival.

Ensuring quality in contextualised cancer management guidelines for resource-constraint settings: using a systematic approach.

To address the wide variation in access to cancer care in India requires strengthening of infrastructure, trained oncology workforce, and minimisation of out-of-pocket expenditures. However, even with major investments, it is unlikely to achieve the same level of infrastructure and expertise across the country. Therefore, a resource stratified approach driven by evidence-based and contextualised clinical guidelines is the need of the hour. The National Cancer Grid has been at the forefront of delivery of standardised cancer care through several of its initiatives, including the resource-stratified guidelines. Development of new guidelines is resource and time intensive, which may not be feasible and can delay the implementation. Adaptation of the existing standard guidelines using the transparent and well-documented methodology with involvement of all stakeholders can be one of the most reasonable pathways. However, the adaptation should be done keeping in mind the context, resource availability, budget impact, investment needed for implementation and acceptability by clinicians, patients, policymakers, and other stakeholders. The present paper provides the framework for systematically developing guidelines through adaptation and contextualisation. The process can be used for other health conditions in resource-constraint settings.

Disseminated peritoneal leiomyosarcomas after laparoscopic "myomectomy" and morcellation.

Herein is reported a case of disseminated peritoneal leiomyosarcoma arising shortly after laparoscopic myomectomy and specimen retrieval with an electromechanical morcellator. The topography of the sarcomas suggests morcellation as a contributing factor. This case shows that caution should be exercised when selecting patients for laparoscopic myomectomy and stresses the need for a thorough pathologic examination of the specimen retrieved.

Long-term survival outcome of advanced epithelial ovarian cancer: A single institutional study.

BACKGROUND: A number of patients with advanced-stage epithelial ovarian cancer do survive beyond 5 years. The long-term follow-up data are limited, especially for the Indian setting. We evaluated the 10-year survival outcome and influencing clinicopathological factors. METHODS: A retrospective analysis of advanced-stage epithelial ovarian cancer patients who underwent primary cytoreductive surgery (PCS) or interval cytoreductive surgery (ICS) from 2005 to 2008 was conducted. Survival analysis was performed with the Kaplan-Meier method, and the Cox proportional hazards model was used for prognostic clinicopathological factors analysis. RESULTS: Ninety-four patients with a median age of 54.5 (18-79) years were evaluated. The median follow-up period was 11.2 years. The overall survival (OS) rates at 5, 7, and 10 years were 37%, 23%, and 18%, respectively. The median OS (MOS) was 46 (95% confidence interval [CI], 36-55.8) months and progression-free survival (PFS) was 19.5 (15.3-23.6) months. Long-term survival was significantly predicted by R0 resection (complete cytoreduction with no macroscopic residual disease) and PFS >20 months while prolonged PFS was influenced by age ≤55 years and R0 resection. For the R0 resection group, patients who underwent PCS had better overall survival in comparison with ICS [72.1(25.2-119) months vs 47.4 (34.9-59.9)months] on 10 years follow-up but was not significant statistically. CONCLUSION: Patients with age ≤55 years, R0 resection, PFS >20 months have a better 10-year survival outcome. Among R0 resection, patients undergoing PCS have clinically a better outcome on 10-year follow-up.

Impact of St. Gallen surrogate classification for intrinsic breast cancer sub-types on disease features, recurrence, and survival in South Indian patients.

BACKGROUND: Breast cancer is a heterogeneous group of disease, and recently, intrinsic sub-typing on the basis of gene expression profiling is found to be a predictor of breast cancer clinical course. The St. Gallen has released surrogate classification for breast cancer sub-types depending on immunohistochemistry (IHC) markers. AIM: The aim of our study was to analyze the distribution of sub-types using IHC surrogate markers in our patient population and to assess the clinico-pathological factors in different sub-types. MATERIALS AND METHODS: A total of 635 non-metastatic patients who underwent radical intend treatment from January 2011 to December 2013 were included for this retrospective analysis. A statistical analysis was done by Windows SPSS version 20. The Chi-square test was used to examine the correlations of these sub-types with clinico-pathological parameters. The Kaplan-Meier method estimates were used for survival analysis. RESULTS: The median follow-up was 42.77 months (5 months to 112 months). Luminal B was the predominant group. Disease free survival (DFS) at 5 years was 95% in luminal A, 78% in luminal B HER-2 negative, 80% in luminal B HER-2 positive, 72% in triple negative, and 79% in HER-2/neu non-luminal. Tumor size, Ki67, T stage, N stage, and grade were significantly associated with DFS in all biological type with a P value of less than 0.05. CONCLUSION: Surrogate classification was successfully applied in our patient cohort. Luminal B and triple negative sub-groups were more prevalent in our patients, and this finding is at variance with published international data. Biological sub-type also emerged as an important predictor of survival.

Pathological Complete Response in Locally Advanced Breast Cancer after Neoadjuvant Chemotherapy: Survival Outcome and Its Relevance as a Surrogate End Point.

Background Pathological complete response (pCR) to neoadjuvant chemotherapy has emerged as a reliable surrogate marker for improved survival in breast cancer (BC), but its role as a surrogate end point is still controversial. Aims and Objectives The aim of the study is to investigate the clinical course of BC patients with pCR and to evaluate the relevance of pCR as a surrogate end point for survival. Materials and Methods This was a single-institution retrospective analysis done at Amrita Institute of Medical Sciences. Records of BC patients from 2004 to 2014 were analyzed. Disease-free survival (DFS) and overall survival (OS) were compared using the Kaplan-Meier method and log-rank test, respectively. pCR and survival association were evaluated using regression analysis ( R 2 ). Results Of 224 patients included in the study pCR rate was 15.2%. The median duration of follow-up was 61 months (range: 3-151 months). DFS (73.4 vs. 46.1%, p = 0.032) and OS (82.5 vs. 56.4%, p = 0.022) of pCR cohort was significantly higher than non-pCR cohort. Recurrence rate was significantly lower in the pCR cohort at: All distant sites ( p = 0.01 3), visceral sites ( p = 0.007), both bone and visceral sites ( p = 0.007), and nodal sites ( p = 0.007). There was no difference in the bone-only recurrence ( p = 0.3 15). Death rate was significantly lower in pCR cohort ( p = 0.007). The R2 value for pCR as a surrogate for DFS and OS was 0.006 and 0.004, respectively. Conclusion pCR is a favorable prognostic factor associated with improved survival. However, there is no association between pCR and survival.

A pilot study to assess the feasibility of evaluation of markers of response to chemotherapy at one day & 21 days after first cycle of chemotherapy in carcinoma of breast: a prospective non-randomized observational study.

BACKGROUND: Interest in translational studies aimed at investigating biologic markers in predicting response to primary chemotherapy (PCT) in breast cancer has progressively increased. We conducted a pilot study to evaluate feasibility of evaluating biomarkers of response to PCT at one & 21 days after first cycle. METHODS: Adult, non-pregnant, non-lactating women with histologically confirmed infiltrating duct carcinoma underwent serial core biopsies after first cycle of PCT and these were scored for Ki-67, Bcl-2 and Caspase-3 using immunohistochemistry. RESULTS: We recruited 30 patients with a mean age of 51 years. We were successful 95.6% times in performing a core biopsy and of these 84.6% had adequate tissue in the cores harvested. After a mean of 4 cycles of PCT, 26 patients underwent surgery and good response was noted in 9 patients (30%) using Miller-Payne criteria. There was a trend noted in all markers, which appeared different in those with good response and poor response. Good responders had significantly higher Ki-67 and significantly lower Bcl-2 at baseline and a significant decrease in Ki-67 and Caspase-3 at 21 days after the first chemotherapy. CONCLUSION: We report a detectable change in biomarkers as early as 24-48 hours after the first chemotherapy along with a definite trend in change that can possibly be used to predict response to chemotherapy in an individual patient. The statistical significance and clinical utility of such changes needs to be evaluated and confirmed in larger trials.

Prognostic significance of residual nodal burden using lymph node ratio in locally advanced breast cancer after neoadjuvant chemotherapy.

OBJECTIVE: To investigate the prognostic value of lymph node ratio (LNR) after neoadjuvant chemotherapy (NAC) according to breast cancer molecular subtypes. METHODS: From 2004 to 2014, patients with definitive surgery after NAC were identified. LNR was calculated for node positive patients who underwent axillary dissection and at least 10 nodes (LNT) were removed. Disease free and overall survivals were analysed using Kaplan-Meier test and compared using log rank test for ypN0-3, LNR categories (LNRC) ≤0.2 (low), 0.21-0.65 (intermediate), >0.65 (high), and single LNR cut-off value. RESULTS: Of 224 analysed patients: ypN0 72 (32.1%), ypN+ 152 (67.9%). Of 118 LNT ≥10 ypN+ patients LNRC: Low risk 48 (40.7%), intermediate risk 36 (30.5%), high risk 34 (28.8%). Factors significantly different in LNR categories were ypN (P < 0.001); extranodal extension (P < 0.001); present status of patients (P < 0.001); and disease status (P = 0.029). LNRC was inversely associated with 5-year DFS: Low 52.3%, intermediate 40%, and high 12.2% (log rank P < 0.001); and OS: Low 64.4%, intermediate 58.3%, and high 13.6% (log rank P < 0.001). Significant association of LNRC and DFS and OS were demonstrated in TNBC (P < 0.001) and HER2 subtypes (P = 0.045 and 0.005 respectively). A single value of LNR = 0.25 in node positive was found significant for DFS and OS in TNBC (P < 0.001) and Her2+ (P = 0.013 and P = 0.001 respectively) but not for HR+ (DFS: P = 0.132; OS: P = 0.144). CONCLUSION: Residual nodal disease after NAC analysed by LNRC or LNR = 0.25 cut-off value, is prognostic and can discriminate between favourable and unfavourable outcomes for TNBC and Her2+ breast cancers.

A retrospective analysis of the pattern of care and survival in patients with malignant ovarian germ cell tumors.

OBJECTIVE: The objective of this study is to evaluate the pattern of care and survival outcome in patients with malignant ovarian germ cell tumors (MOGCTs). MATERIALS AND METHODS: Between January 2004 and August 2017, 50 patients with MOGCT were identified at Amrita Institute of Medical Sciences and 48 included in analyses. Histologic subtypes were as follows: dysgerminoma 11; immature teratoma 16; yolk sac tumor 3; and mixed germ cell tumor 18. 31 (64.6% patients belonged to Stage I and 17 (35.4%) patients were advanced stage (Stage II-IV). RESULTS: Median follow-up period was 34 months (range: 1-241 months). The 5- and 10-year disease-free survival (DFS) and overall survival (OS) for the entire cohort were 87.5% and 94.4%, respectively. DFS and OS of incomplete surgery Stage I patients 28.6% and 68.6%, respectively, were significantly lower than completely staged patients 100%. Out of 8 incomplete surgery patients, 5 recurred of which 2 died of disease within 4 and 9 months of recurrence. There was no survival difference with comprehensive surgical staging (CSS) and pediatric surgical staging (PSS) in Stage I MOGCT (DFS and OS 100%). Stage I dysgerminoma kept on active surveillance after PSS had equivalent survival of 100%. There was no survival difference in advanced stage MOGCT treated with primary debulking surgery and neoadjuvant chemotherapy (NAC) followed by fertility-sparing surgery (DFS and OS 100%). CONCLUSION: Incomplete surgery in Stage I MOGCT was associated with poor survival. There was no survival difference with CSS and PSS. NAC followed by surgery could be a reasonable option for patients of advanced stage MOGCT.

Breast Cancer Care in South India: Is Practice Concordant With National Guidelines?

PURPOSE: The National Cancer Grid (NCG) of India has recently published clinical practice guidelines that are relevant in the Indian context. We evaluated the extent to which breast cancer care at a teaching hospital in South India was concordant with NCG guidelines. METHODS: All patients who had surgery for breast cancer at a single center from January 2014 to December 2015 were included. Demographic, pathologic, and treatment characteristics were extracted from the electronic medical record. Patients were classified as being concordant with six elements selected from the NCG guideline. The indicators related to appropriate use of sentinel lymph node (SLN) biopsy, lymph node harvest, adjuvant radiotherapy, adjuvant chemotherapy, human epidermal growth factor receptor 2 (HER2) testing, and delivery of adjuvant trastuzumab. RESULTS: A total of 401 women underwent surgery for breast cancer; mean age (standard deviation) was 57 (12) years. Lymph node involvement was present in 47% (188 of 401) of the cohort; 23% (94 of 401) had T1 disease. Ninety-two percent (368 of 401) underwent radical modified mastectomy. SLN biopsy was performed in 75% (167 of 222) of eligible patients. Eighty percent (208 of 261) of patients with a positive SLN biopsy or no SLN biopsy had a lymph node harvest of more than 10. Adjuvant chemotherapy with an anthracycline and a taxane was delivered to 67% of patients (118 of 177) with node-positive disease. Adjuvant radiotherapy was delivered to 84% (180 of 213) of patients with breast-conserving surgery, T4 tumors, or 3+ positive lymph nodes. Fluorescent in situ hybridization testing was performed in 59% of patients (43 of 73) with 2+ HER2-positive lymph nodes on immunohistochemistry. Among patients with HER2 overexpression, 40% (36 of 91) received adjuvant trastuzumab. CONCLUSION: Concordance with NCG guidelines for breast cancer care ranged from 40% to 84%. Guideline concordance was lowest for those elements of care associated with the highest direct costs to patients.

Irrigation-coupled bipolar cautery unit: A practical, economical, and simple version.

Hemostasis is a fundamental principle of surgery for which electrocoagulation is universally used. Bipolar electrocautery has an advantage over monopolar electrocautery in terms of the precision of the extent of tissue coagulation and the lateral extent of thermal tissue injury. However, secondary to the thermal changes induced in the tissue due to electric current passage, there is charring of tissue, which adheres to the cautery tip. This, not only decreases its effectiveness, but also, by getting avulsed while removing the cautery tip from the surgical field, causes rebleeding and more trauma to the tissue. Irrigation of the surgical field during application of cautery reduces the charring effect, thereby improving the efficiency and efficacy. Irrigation-coupled electrocautery devices are available but are costly to acquire and maintain. We describe a simple and reliable version of an irrigation-coupled cautery device, which is of immense functional utility in our experience. It decreases the amount of charring of the tissue and its adherence to the bipolar forceps tips, thereby decreasing the frustrating loss of effectiveness and also increases the life of the bipolar forceps as cleaning needs to be less frequent. By virtue of its simplicity and cost-effectiveness, it can be used in almost all hospitals and situations.

Advanced Primary Epithelial Ovarian and Peritoneal Carcinoma-Does Diagnostic Accuracy of Preoperative CT Scan for Detection of Peritoneal Metastatic Sites Reflect into Prediction of Suboptimal Debulking? A Prospective Study.

Ovarian cancer is the seventh most common cancer in females worldwide. Optimal debulking is the standard treatment but possible only in 30-85% of advanced stages. Knowing exactly the disease extent preoperatively may predict suboptimal debulking. We analyzed diagnostic accuracy of preoperative CT scan in disease mapping and prediction of suboptimal debulking in a prospective observational study from March 2013 to May 2015 in a tertiary hospital. Adults below the age of 75 years with ECOG PS-0, 1, 2, clinically/radiologically newly diagnosed stage IIIc epithelial ovarian (EOC), and primary peritoneal carcinoma (PPC) were included. Neoadjuvant chemotherapy recipients were excluded. Preoperative multidetector CT (MDCT) scan showing deposits at 19 predetermined abdominopelvic sites were compared with the same sites seen at laparotomy and corresponding accuracies of CT scan calculated. Primary debulking surgery was done to achieve debulking to nil or less than 1-cm residual disease. Stepwise logistic regression models were used to determine the frequent suboptimal debulking sites and the predictive performance of the clinical and CT scan findings. A total of 36 patients were enrolled. The optimal debulking rate was 50%. The CT scan could detect the disease-bearing sites with overall sensitivity of 68.29%, specificity of 89%, accuracy of 78.07%, and positive and negative predictive values of 99 and 50.1%, respectively. Upon multivariate analysis, bowel mesentery (p 0.011) and omental extension (p 0.025) were associated with suboptimal debulking. CT scan accuracy at these sites (predictive performance) was 86.1%. We identified small bowel mesentery and omental extension (to spleen/stomach/colon) as sites associated with suboptimal debulking. MDCT accurately depicts peritoneal metastases, although sensitivity is reduced in certain areas of significance for optimal debulking. Further validation with more number of patients is warranted.

Feasibility study of axillary reverse mapping lymphoscintigraphy in carcinoma breast: A concept toward preventing lymphedema.

OBJECTIVE: In the surgery of breast cancer, axillary reverse mapping (ARM) is the identification and preservation of arm draining lymph node (ARM node) during an axillary dissection. The assumption is that the ARM node is different from node draining breast and is unlikely to be involved even in the patients with axillary nodal metastases. If we can identify and preserve ARM node using lymphoscintigraphy; morbidity of lymphedema, as seen with axillary dissection, may be avoided. MATERIALS AND METHODS: Pathologically proven 50 breast cancer patients undergoing initial surgery (cTx-4, cN0-2, and Mx-0) were included in this study. Less than 37 MBq, 0.5 ml in equally divided doses of filtered 99mTc sulfur colloid was injected intradermally into the second and third web spaces. ARM nodes in the axilla were identified with the help of Gamma Probe intraoperatively; however, their location was noted with the reference to specific anatomical landmarks and sent for histopathological examination after excision. RESULTS: The ARM node was successfully identified in 47/50 cases (sensitivity - 94%). In 40 out of 47 cases (85%), the location of the ARM node was found to lateral to the subscapular pedicle, above the second intercostobrachial nerve and just below the axillary vein. Of the 47 patients in whom ARM node/s were identified, metastasis was noted in 5 of them (10%). Four out of these 5 patients had the pN3 disease. CONCLUSION: ARM node exists, and it is feasible to identify ARM node using radio isotope technique with an excellent sensitivity. ARM node seems to have a fairly constant location in more than 80% cases. It is involved with metastasis (10% cases) only when there are multiple lymph nodal metastases in the axilla.