Evaluation of axillary lymph nodes in breast cancer patients with clinically negative axilla using contrast enhanced ultrasonography.

Contrast enhanced ultrasonography enables dynamic evaluation of the microvasculature down to the capillaries when using high resolution ultrasound probes. It's application in the evaluation of axillary lymph nodes in breast cancer patients with clinically negative axilla has been studied in 42 patients. The results of pre operative CEUS evaluation was correlated with histopathology status of axillary nodes after the harvesting of nodes during modified radical mastectomy or sentinel node biopsy. Heterogeneous enhancement with micro bubbles of the axillary nodes was found to be the most distinguishing criteria for malignant nodes.

Phantom Hernia: A Rare Sequela of Herpes Zoster Infection.

The herpes zoster (HZ) virus first manifests as varicella, or chickenpox, in children and remains dormant in the dorsal root ganglia of the nerves. The vesicular eruptions that might be painful develop along a dermatome when the virus is reactivated. While postherpetic neuralgia is a well-known side effect of herpes simplex, there are well-reported motor consequences as well. Segmental zoster paresis is an uncommon motor consequence of herpes zoster that resembles an anterior abdominal wall hernia but does not require surgery in contrast to an actual abdominal wall hernia. We present a similar case of a 46-year-old male who presented with classic herpes zoster rash and phantom hernia as a rare sequela of this condition.

Efficacy of platelet-rich plasma in alleviating split skin graft morbidities.

Introduction: Skin grafting is a routinely employed technique to cover the skin defect. Though the skin grafts are technically effortless, they are tiresome because of the prolonged duration of hospital stay, labor-intensive, demanding repeated dressings, and also create a second wound. Platelet-rich plasma (PRP) is one that has a higher concentration of platelets than the blood. Alpha granules of the platelets are rich in growth factors. Aims and Objectives: To assess the effect of PRP on split-thickness skin graft uptake and donor site healing. Materials and Methods: In a single-center-based prospective study done from August 2018 to June 2020, 60 patients with acute and chronic wounds were divided into two equal groups. Autologous PRP was applied on the recipient wound bed and donor site in PRP group, and conventional methods like staples/sutures were used to anchor the skin grafts and standard of care of the donor site in a control group. Results: Instantaneous graft adhesion was observed in all patients of PRP group. The first graft inspection was delayed. Seroma, hematoma, total number of dressings, and duration of stay in hospital were significantly reduced in the PRP group. Donor site pain in the postoperative period was notably reduced in PRP group. PRP also remarkably hastened the donor site healing. Conclusion: The application of PRP promotes graft take, minimizes complications, enhances donor site wound healing, mitigates donor site pain, and has immense economic benefits due to the reduced number of dressing changes and shorter hospital stay.

A Case Series on Acute Mesenteric Ischemia (AMI) Leading to Intestinal Gangrene Following Blunt Trauma to the Abdomen.

The term "acute mesenteric ischemia" (AMI) refers to a set of conditions where the blood supply to various segments of the small intestine is cut off, causing ischemia and subsequent inflammatory changes that might result in bowel gangrene. Estimates place the incidence between 0.09% and 0.2% of all acute surgical hospitalizations. Early diagnosis is essential, despite the entity being a rare cause of abdominal discomfort, because if left untreated, mortality is 50%. Herein, we present a case series of three patients with bowel ischemia following blunt abdominal trauma.

Role of Diffusion-Weighted Magnetic Resonance Imaging in Prediction of Pathological Complete Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer and Its Molecular Subtypes.

Purpose The aim of this study was to evaluate the role of apparent diffusion coefficient (ADC) and hence diffusion-weighted imaging in prediction of pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) in locally advanced breast cancer (LABC) and its molecular subtypes. Methods In this tertiary hospital-based prospective study, 30 patients aged 30 to 65 years, having clinically/cytologically diagnosed LABC, were included. Magnetic resonance imaging (MRI) was done to obtain prechemotherapy ADC (ADC pre ), postchemotherapy ADC (ADC post ), change in ADC (ΔADC), and ΔADC% for each tumor and its subtype. Postsurgical pCR was used as the reference standard for determining tumor response. All four ADC parameters were compared between pCR and non-pCR groups. Results Of the 30 patients, 19 (63.3%) patients showed pCR, while 11 (36.7%) patients did not. The pCR group showed significantly lower mean ADC pre ( p < 0.001) and higher mean ADC post ( p < 0.05), ΔADC, and ΔADC% ( p = 0.000) than non-pCR group. The best cutoff values to differentiate responders from nonresponders with receiver operating characteristic curve analysis of ADC pre , ADC post , and ΔADC% were 0.98 × 10 -3 mm 2 /s (68.4% sensitivity, 63.6% specificity), 1.31×10 -3 mm 2 /s (68.4% sensitivity, 63.6% specificity), and 25% (84.2% sensitivity, 90.9% specificity), respectively. Human epidermal growth factor receptor 2 (HER2)-enriched subtype showed significant difference in mean ADC pre ( p = 0.045), while triple-negative subtype showed significant differences in mean ADC post ( p = 0.032) and mean ΔADC ( p = 0.019) between the two groups. Conclusion ADC pre , ADC post , and ΔADC can predict pCR to NACT in LABC. Among molecular subtypes, ADC pre was predictive only in HER2-enriched subtype, while ADC post and ΔADC were predictive only in triple-negative subtype.

Analysis of Isocitrate Dehydrogenase -2 (IDH-2) Activity in Human Serum as a Biomarker in Chemotherapy Patients of Breast Carcinoma: A Case-Control Study.

INTRODUCTION: Breast cancer represents a major public health problem in women worldwide. For many cancers, serum tumour markers play an important role in patient treatment and monitoring. Isocitrate dehydrogenase enzyme is also used as a biomarker for various types of cancer. AIM: The purpose of this study was to determine serum Isocitrate dehydrogenase-2 (IDH-2) enzyme activity in breast cancer patients (pre and post chemotherapy) and also correlate the changes in enzyme activity with stages of cancer and control groups. MATERIALS AND METHODS: In this case-control study, histologically confirmed 40 female patients aged 28-80 years who fulfilled the criteria for diagnosis of invasive breast cancer were selected in our study groups from surgery outpatient department of SS Hospital, BHU, Varanasi, India, and 40 healthy age matched females were selected between October 2013 to July 2015. The estimation of serum IDH-2 enzyme activity in before and after two cycles of neoadjuvant chemotherapy patients was performed by spectrophotometry assay. RESULTS: The mean serum IDH-2 activity in cases (Mean±SD) was significantly more than control group (p<0.001). The mean serum IDH-2 activity in cases was significantly decrease after neo-adjuvant chemotherapy (p=0.019). In stage II pre chemotherapy patients serum IDH-2 activity was higher than post chemotherapy (p<0.05), but in stage III the correlation between pre and post chemotherapy patients serum IDH-2 activity was not significant (p-value>0.05). CONCLUSION: The serum IDH-2 can be a potential biomarker in breast carcinoma and can be used for prognosis and monitoring the chemotherapy response of the patients.

Distal Duodenal Obstruction: a Surgical Enigma.

The postbulbar segment also known as the distal duodenum is a separate clinical entity in terms of the intrinsic pathologies of this region and its varied anatomical relations. The common bile duct and the pancreatic duct open through the major papilla, which marks the beginning of this segment. Distal duodenal obstruction can be defined as a clinicoradiological entity that is characterized by features of gastric outlet obstruction with recurrent bilious vomiting and a radiological evidence of postbulbar obstruction. A Medline search for distal duodenal obstruction revealed 1409 entries, mostly in the form of case reports. In the last 10 years, 310 cases are reported. Clinical features like abdominal pain, nausea, and vomiting are non-specific and quite similar to gastric outlet obstruction. Clinical findings are also non-specific and do not aid in diagnosis. Laboratory findings also do not add much. Contrast-enhanced CT scan and MR enterography are diagnostic modalities of choice. Distal duodenal obstruction is a clinical entity that has a wide list of differential diagnosis which requires due consideration in terms of its management and follow-up. Most of these lesions require adequate workup with the help of a multidisciplinary team consisting of radiologists, gastroenterologists, and pathologists to adequately diagnose and stage the disease before a treatment plan is formulated. A thorough knowledge is a must regarding the treatment options available for each of the conditions so that the management can be personalized leading to better results.

Epidemiological Study of Triple-Negative Breast Cancer Patients in North Indian Population: a Hospital-Based Study.

Triple-negative breast cancer (TNBC) accounts for 10-25% of all breast tumors. This makes it more difficult to treat, so triple-negative cancers often require targeted therapies. We studied the prevalence of TNBC in a hospital-based study and compared the clinicopathological characteristics of triple-negative and non-triple-negative breast tumors. One hundred three patients were included in the study that underwent modified radical mastectomy. The procedure of immunostaining was performed using formalin-fixed, paraffin-embedded tissue sections. These sections were stained immunohistochemically for ER, PR, and HER2 neu by using ready-to-use monoclonal antibody detection system with 3'-3' diaminobenzidine hydrochloride (DAB) as chromogen. Of all 103 patients, 35 (34%) were triple negative. The average age of patients of TNBC and non-TNBC group was found as 44.16 and 40.73 years, respectively. Patients of post-menopausal state were higher than premenopausal in TNBC (22/35; 62%) and non-TNBC groups (45/68; 66%). Further, TNBC patients reported at clinically early stages I and II (18/35; 51.4%) while non-TNBC patients predominantly reported at later stages III and IV (44/68; 64.7%). It was also observed that breast tumor size in majority of the patients in both groups lies between 2 to 5 cm (TNBC = 23/35; 65.7% and non-TNBC = 35/68; 51.5%). Lymph node metastases were present in 51.5% (18/35) cases in TNBC patients and 64.7% (44/68) cases in non-TNBC group. Despite the limitation of less number of breast cancer cases, we analyzed that TNBC tumors have aggressive clinical values than non-TNBC, though having no statistically significant difference between the prognostic clinical parameters of two groups.

Carcinoma in accessory axillary breast.

We present a rare case of carcinoma developing in an accessory breast. The patient presented with a progressive lump in her right axilla for 1 year. On examination, there was a well-developed nipple areola complex in the right axilla overlying a hard, fixed 5 × 3 cm lump. On investigation, core biopsy revealed poorly differentiated carcinoma of the breast. Mammography also revealed features of a malignant lesion with skin and muscle infiltration. Neoadjuvant chemotherapy was administered followed by modified radical mastectomy after three cycles. Immunohistochemistry study showed positive status of oestrogen and progesterone receptors, and negative HER-2 neu. Three more cycles of chemotherapy along with 50 Gy radiotherapy were given in an adjuvant setting followed by hormone therapy.

Association between biomarkers of oxidative stress, trace elements, and cell proliferation index in patients with benign and malignant breast diseases.

OBJECTIVES: To understand the association between biomarkers of oxidative stress, antioxidants, trace elements, and cell proliferation index in relation to the disease progression in the pathophysiology of breast diseases. DESIGN AND METHODS: Concentrations of markers of oxidative stress, antioxidants, trace elements, and cell proliferation index were evaluated in the patients with benign breast diseases, malignant breast diseases, and healthy volunteers as controls. Multinomial logistic regression analysis was used to identify the contribution of the selected indexes using odds ratio and associated confidence interval. RESULTS: The level of markers of oxidative stress (malondialdehyde [MDA]) and cell proliferation index were found to be significantly higher with significantly depleted levels of antioxidants and trace elements in breast cancer patients compared with control subjects as well as benign breast disease patients. A similar pattern of changes were observed between benign and control subjects. CONCLUSION: An inadequate amount of antioxidant enzymes and trace elements may be an important contributing factor associated with oxidative stress leading to elevated levels of MDA and cell proliferation index in relation to disease progression and clinical stage in the pathophysiology of breast diseases.

Correlation of serum toll like receptor 9 and trace elements with lipid peroxidation in the patients of breast diseases.

Toll-like receptors are recognized as redox sensitive receptor proteins and have been implicated in cellular response to oxidative stress. Altered pro-oxidant-antioxidant balance leads to an increased oxidative damage and consequently play an important role in breast diseases. The study was designed to access the oxidative stress status by quantification of byproducts generated during lipid peroxidation and inadequate trace elements during oxidative damage and its effects on the toll like receptor (TLR) activity in patients of breast diseases. Decreased levels of selenium, copper, zinc, magnesium and iron with elevated levels of malondialdehyde (marker of lipid peroxidation) were accompanied by decreased TLR activity in patients of benign breast diseases as well as breast carcinoma. A similar pattern was observed with the advancement of disease and its subsequent progression in breast carcinoma patients. Results of multinomial regression analysis suggest benign breast disease patients are at higher risk of developing breast cancer with high odds ratio of lipid damage.

Jejunojejunal intussusception with internal herniation in the stomach.

Jejunojejunal intussusception with internal herniation of the stomach through a gastrojejunostomy stoma is one of the rarest complications of the previous gastric surgery. The incidence is reported to be less than 0.1 %. An elderly male presented to the emergency room with signs of intestinal obstruction for 1 day. There was also history of appearance of a lump in the mid-abdomen. A primarily healed midline scar of the previous surgery was present; the details of which were not known. X ray abdomen in the erect posture showed multiple air fluid levels. Ultrasonography (USG) revealed dilated stomach with central hyperechogenicity with a peripheral rim of decreased echogenecity. Contrast-enhanced computed tomography (CECT) scan showed jejunojejunal intussusception with internal herniation of the stomach. On laparotomy, it was found that there was a previous gastrojejunostomy with jejunal invagination leading to gangrene of a segment. Resection anastomosis was done. The postoperative period was uneventful.

Expression of serum toll-like receptor 9 and oxidative damage markers in benign and malignant breast diseases.

The intracellular redox environment plays an important role in the maintenance of proper cellular homeostasis and functions. Disturbances in redox equilibrium of cells result in pro-inflammatory conditions, and these inflammatory conditions can induce carcinogenesis or increase the malignant potential of the tumor. Oxidative stress or tissue damage can trigger toll-like receptor (TLR) family of receptors that are involved in altering the innate immune system. The present study was aimed at evaluating the level of oxidative damage markers in breast diseases by measuring the 8-hydroxydeoxyguanosine (8-OHdG), protein carbonyl (PC), malondialdehyde (MDA), and total antioxidant status (TAS) alterations in relation to expression of TLR-9. A significant increase in the level of oxidative damage markers was observed in breast carcinoma patients in comparison to benign and normal controls, which was accompanied by a significant decrease in TAS and expression of TLR-9 concentrations. 8-OHdG, PC, and MDA were negatively correlated with expression of TLR-9 and TAS levels. Altered levels of biomarkers of oxidative stress and TLR-9 among the malignant, benign, and controls suggest a correlation of oxidative stress and TLR signaling in the progression of disease in breast carcinoma patients. Receiver operating characteristic analysis depicts that expression of TLR-9 is a good indicator for distinguishing cancer patients from benign and normal controls. High accuracy, specificity, and sensitivity of oxidative stress markers and expression of TLR-9 can be used as discriminatory marker/s for efficient diagnosis.

NF-κB p65 subunit DNA-binding activity: association with depleted antioxidant levels in breast carcinoma patients.

NF-κB is recognized as a redox-sensitive transcription factor and has been implicated in cellular response to oxidative stress. The study was designed to correlate the changes in antioxidant status with the levels of nuclear factor-κB (NF-κB) p65 subunit DNA-binding activity in relation to lymph node involvement, tumor size, and staging in breast carcinoma patients. Case control study comprised of 40 breast carcinoma patients along with 40 age- and sex-matched healthy subjects as controls. Levels of enzymatic/nonenzymatic antioxidants along with the trace elements were measured to study the antioxidant status in the study subjects. Levels of NF-κB p65 subunit DNA-binding activity was estimated by ELISA assay. The levels of enzymatic, nonenzymatic antioxidants, and trace elements were found to be significantly depleted in breast carcinoma patients in comparison to healthy controls suggesting significantly decreased levels of antioxidant activity in the breast carcinoma patients. Also, these results indicate that antioxidant levels decrease progressively with the advancement of stage and subsequent progression of disease. DNA-binding activity of NF-κB p65 subunit was higher in breast cancer patients in comparison to normal healthy controls, and the activity was found to increase with the advancement of disease. Significant correlation was observed between the DNA-binding activity of NF-κB p65 subunit and antioxidant status in the patients. The logistic regression analysis revealed decreased levels of antioxidants and increased level of DNA-binding activity of NF-κB p65 subunit were significantly associated with incidence of breast carcinoma. Depleted antioxidant status and increased level of DNA-binding activity of NF-κB p65 subunit thus point clearly of an association in relation to disease progression, clinical stage, and cytological grade in the pathophysiology of breast carcinoma.

Oxidative damage markers as possible discriminatory biomarkers in breast carcinoma.

The study was designed to evaluate the markers of oxidative damage and to establish their diagnostic utility in breast carcinoma patients. Levels of 8-hydroxy-2-deoxyguanosine (8-OH-dG), protein carbonyl (PC), and malondialdehyde (MDA) along with total antioxidant status (TAS) were measured in breast carcinoma patients and controls. Receiver operating characteristic (ROC) analysis was done to study the diagnostic potential of the oxidative damage markers. Significant increases in oxidative damage markers were observed in breast carcinoma patients compared with the normal controls, which were accompanied by significant decrease in TAS. The logistic regression analysis revealed higher levels of oxidative stress marker and reduced level of TAS were significantly associated with breast cancer. ROC curves analysis demonstrates that 8-OHdG and PC are better indicators for distinguishing cancer patients from controls, followed by MDA and TAS. Our results indicate increased oxidative damage is associated with malignancy in breast cancer patients. High accuracy of oxidative stress markers in indicating cancer presence can be used as discriminatory makers for efficient diagnosis.

An unusual presentation of ovarian teratoma: a case report.

Mature cystic teratomas account for 10-20% of all ovarian neoplasms and are the most common neoplasm in younger patients. Spontaneous rupture of the teratoma is rare and has been occasionally reported. Here we present an unusual case of left ovarian teratoma rupturing into sigmoid colon.

Parathyroid incidentaloma.

Incidentalomas are lesions which are asymptomatic and detected incidently during imaging or surgery. Parathyroid incidentalomas are a rare entity. Enlargement of gland without hyperfunction may be an early stage of disease. Symptomatology is usually non-specific or related to renal and skeletal system. Total serum calcium estimation may be used as a screening modality. Sestamibi scan is a more accurate imaging technique than USG. FNAB - PTH measurement is the most reliable minimally invasive nonsurgical test for parathyroid tissue verification. Incidently discovered enlarged parathyroid gland may be removed to avoid a re-do surgery.

Vascular endothelial growth factor levels in relation to oxidative damage and antioxidant status in patients with breast cancer.

PURPOSE: Oxidative stress and angiogenesis are important elements in the pathogenesis of inflammatory diseases and cancer. Vascular endothelial growth factor (VEGF) is one of the most potent angiogenic cytokines and is up-regulated by conditions associated with the generation of free radicals and reactive oxygen intermediates. In this study, we investigated the association between oxidative stress and serum VEGF status in patients with breast cancer. METHODS: Forty patients with breast carcinoma, of which 21 were stage II and 19 were stage III, along with 40 age- and gender-matched healthy controls were enrolled. Oxidative stress, total antioxidant status, and VEGF levels in serum were evaluated by spectrophotometric procedures. Malondialdehyde (MDA) levels were measured and antioxidant status was assessed by measuring total antioxidant status (TAS) to assess oxidative damage. RESULTS: VEGF and MDA levels were significantly higher in patients with breast cancer than those of controls (p<0.005). Total antioxidant level decreased significantly in patients compared to that in controls. MDA, TAS, and VEGF levels were also analyzed based on menopausal status and different clinical disease stages. MDA and TAS level significantly different in the postmenopausal group than the premenopausal group, whereas VEGF level remained unchanged. CONCLUSION: Increased VEGF level and its positive correlation with oxidative stress level and decreased antioxidant status suggest a link between oxidative stress and malignant transformation.

Squamous cell carcinoma developing in a diabetic foot ulcer.

Documented cases of malignant transformation of foot ulcer in a diabetic patient in medical literature are very few. This study presents 2 interesting cases of long-standing diabetic foot ulcer, which were subsequently diagnosed to have squamous cell carcinoma on histopathological examination.

Touch imprint cytology evaluation of sentinel lymph node in breast cancer.

BACKGROUND: Most centers use lymphoscintiscan for identification of a sentinel lymph node (SLN) and frozen section for its evaluation. The aim of the present study was to assess the accuracy of peritumoral methylene blue dye injection for SLN identification and the technique of touch imprint cytology (TIC) for its evaluation. PATIENTS AND METHODS: One hundred and eight fine needle aspiration cytology (FNAC)-proven breast cancer patients with clinically N0 axilla were recruited for the study. Prior to the induction of anesthesia, 5 ml of 1% methylene blue was injected in the peritumoral region to stain the sentinel node, following which conventional modified radical mastectomy was performed. Touch imprint cytology was obtained from the cut surface of the SLN, and then the SLN along with all nonsentinel nodes were sent for histopathology. RESULTS: Intraoperative identification of a blue node was possible in 102 of 108 patients (94%). Touch imprint cytology had a sensitivity of 88%, specificity of 98%, and overall diagnostic accuracy of 94% for diagnosing metastasis in the SLN. The false positive rate for malignancy of TIC versus histology was 2.5% and the false negative rate 7.8%. CONCLUSIONS: Blue dye lymphatic mapping by peritumoral injection of methylene blue was found to be accurate and cost effective for SLN identification. It avoids the expenses of lymphoscintiscanning, which requires special infrastructure and expertise with a significant learning curve. The identified SLN can, with reasonable accuracy, be assessed for metastasis by TIC. The frequently used method of frozen section requires a cryostat and a pathologist trained in the technique. Additionally scanty SLN tissue can be wasted in the cryostat and freezing artifacts can be introduced in the imprint, both of which are avoided by TIC.