Psychosocial well-being and quality of life in women with breast cancer in foothills of North India.

Introduction: Breast cancer remains a leading cause of unintended death among Indian women. Cancer treatment-induced pain, fatigue, nausea/vomiting, body image, and sexual problems could affect the patient psychosocial well-being and quality of life (QOL). The study aims to determine the QOL and psychosocial well-being among women with breast cancer. Materials and Methods: A cross-sectional survey completed by 244 women with breast cancer at a tertiary level teaching hospital. The European Organisation for Research and Treatment of Cancer QOL Questionnaire C30, the Breast Module (QLQ-BR23), and the Hospital Anxiety and Depression Scale (HADS) is used to measure the QOL, and psychological well-being, respectively. Appropriate descriptive and inferential statistics are applied to compute the results. Results: The total number of women with breast cancer interviewed was 244, with a mean age of 45.06 (standard deviation ± 11.17) years. The mean global health score was 70.97 ± 15.63. As per the QLQ-C30 scale, "physical functioning" scored the highest (70.54 ± 22.00), and "role functioning" reported the lowest (49.45 ± 36.15) mean score. Further, on the QLQ-C30 symptoms scale, "appetite loss" (45.09 ± 35.09) was the worst reported symptom, followed by "nausea and vomiting" (34.97 ± 38.39). On the BR-23 scale, body image said (68.42 ± 22.28) higher score than other domains and experience of arm-related problems (43.80 ± 26.06) were more frequently reported symptom in women. As per the HADS scale, 24.6% and 36.1% of women were in moderate anxiety and depression, respectively. The mean HADS score was 14.39 ± 5.82. Findings on predictors for the individual patient remained the same as that earlier published literature. Conclusions and Recommendations: Women with breast cancer have an overall good QOL and poor psychosocial well-being. However, using a holistic approach, including identifying psychological problems and their time management, signifies the need for the studied population.

Detecting Human Epidermal Growth Factor Receptor 2 (HER2) Amplification: Proof of Concept of an Alternative Approach.

BACKGROUND: There are multiple genes that are co-amplified along with human epidermal growth factor receptor 2 (HER2) in chromosome 17. GRB7 and PGAP3 are two such genes. We hypothesize that the protein products of these genes may serve as immunohistochemistry (IHC) markers for detecting HER2 amplification in breast cancer. METHODS: Tissue sections from one hundred and thirty-five primary breast carcinoma cases were subjected to immunohistochemical staining for antibodies against HER2, GRB7, and PGAP3 and graded on a scale of 1 to 3. Both membranous staining and cytoplasmic staining were assessed for GRB7 and PGAP3. For equivocal HER2 IHC positivity, fluorescent in situ hybridization was performed to get the final HER2 status. RESULTS: IHC staining for GRB7 and PGAP 3 was a moderate to strong predictor for HER2 status (area under the curve (AUC) of 0.768, 0.868,0.754, and 0.790 for GRB7 membranous staining, GRB7 cytoplasmic staining, PGAP3 membranous staining, and PGAP3 cytoplasmic staining respectively). A combination of GRB7 cytoplasmic and PGAP3 membranous staining resulted in an AUC of 0.905 (95% CI 0.855-0.954), while a combination of GRB7 and PGAP3 cytoplasmic staining resulted in an AUC of 0.902 (95% CI 0.851-0.953). CONCLUSION: The point estimates for the AUC of GRB7 and combined GRB7 and PGAP3 in predicting the AUC suggest a strong predictive ability of these markers to predict HER2. With further refinement in technique, cytoplasmic staining and membranous IHC staining for GRB7 and PGAP3 have potential to serve as surrogate markers for HER2 status. The strategy of using protein products of co-amplified genes of HER2 is likely to be successful in technical validation.

Pectoralis major muscle sarcoma masquerading breast lesion: A rare case report with review of literature.

Pectoralis major muscle sarcomas are extremely rare and can mimic breast lesion clinically. We report a case of poorly differentiated sarcoma of the pectoralis major muscle in a 63-year-old woman of south east Asian ethnicity presenting with a progressively increasing right breast lump. Mammography, ultrasonography (US), contrast-enhanced computed tomography, and biopsy were done to make the final diagnosis. Complete surgical excision was planned but deferred due to pulmonary metastasis, and the patient was treated with palliative chemotherapy. Clinical examination may be confusing but radiological and pathological investigations provide detailed information about the location and the extent of the disease and a definitive tissue diagnosis can only be made on histopathology which will be helpful in preoperative planning and further treatment of the patient.

Relationship of Tubule Formation, Indian File Pattern and Apocrine Change With Estrogen and Progesterone Receptors and HER2 Immunostaining.

OBJECTIVES: In breast carcinomas, histomorphological features like low-grade and lobular differentiation are associated with estrogen receptor (ER) and progesterone receptor (PR) expression. Apocrine carcinoma is associated with human epidermal growth factor receptor 2 (HER2) positivity. Studies have not emphasized the association between other histological features like tubule formation, Indian file pattern and apocrine change (which may be found in all grades of tumors or as a part of a mixed pattern of no special type) and immunohistochemistry (IHC). The study was designed to find the association between these morphological factors and ER, PR and HER2 status. MATERIALS AND METHODS: The presence or absence of tubule formation, Indian file pattern and apocrine change was correlated with ER, PR and HER2 expression in core biopsies of 102 invasive breast carcinomas. STATISTICAL ANALYSIS: Fisher exact test with median unbiased odds ratio was used. RESULTS: Tubule formation and/or Indian file pattern were significantly associated with ER in all tumors (P-value <0.001), as well as separately for grade II, grade III, HER2-negative and HER2-positive tumors. Comparable results were obtained for their association with PR. Apocrine change was significantly associated with HER2 in all tumors (P-value <0.001), as well as separately for grade III, ER-positive and ER-negative tumors. CONCLUSION: These histomorphological patterns are modest predictors of IHC status in breast carcinomas, even in tumors of higher grade. Knowledge of these morphological correlates of ER, PR and HER2 in breast cancer may serve as an aid in the quality management of breast carcinoma reporting.

Expression of Programmed Cell Death-1 (PD-1) and Its Ligand (PD-L1) in Breast Cancers and Its Association with Clinicopathological Parameters.

Introduction Cancer immunotherapy targeting the programmed cell death ligand 1 (PD-L1) and programmed cell death-1 (PD-1) axis has revolutionized cancer therapy. PD-L1 also serves as a predictive marker for such therapy. To assess the potential of such therapy in any cancer, the positivity of PD-1 and PD-L1 in such cancers needs to be assessed. However, such studies for breast cancer are lacking in South Asia. We aimed to estimate the positivity of PD-L1 and PD-1 receptors in breast cancer and its various clinicopathological groups in our patient population. Materials and Methods We studied the immunoexpression of PD-1 and PD-L1 in 103 histologically proven invasive carcinoma breast cases from October 2018 to April 2019. The percent positivity of PD-1 and PD-L1 with 95% confidence intervals (CI) was estimated for all the cases as well as groups defined by stage, grade, molecular subtype, hormone receptor status, K i -67, and age. Results PD-1 positivity was seen in 72 (69.9%) cases (95% CI: 60.1-78.6). PD-L1 immunoexpression was seen in 61 (59.2%) cases (95% CI: 49.1-68.8) in immune cells and in 39 (37.9%) cases (95% CI: 28.5-50.0) in tumor cells. No significant association was found between PD-1, PD-L1 and age, overall clinical stage, grade, size, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and K i -67. Moderate-to-high PD-1 and PD-L1 immunopositivity was seen in all subtypes of breast cancer. Conclusion PD-1 and PD-L1 is expressed in all subgroups of breast carcinoma. Patients in all such groups are amenable to immunotherapy, provided they are found suitable otherwise.

Evaluation of an Interventional Health Education Project: Screening of Breast Cancer and Health Education (SHE).

There is an increasing incidence of breast cancer in India, especially among younger women. The study's main objective was to create awareness related to breast cancer and breast self-examination by community health workers and assess the effectiveness of improving knowledge and practice. Secondary objective was to conduct clinical breast examination (CBE) of women and prompt referral. METHODS: An outcome evaluation of the Educational Interventional project was conducted in a hilly district of Uttarakhand. Twenty Accredited Social Health Activists (ASHA) were identified and trained in breast cancer awareness, the procedure of breast self-examination, and screening methods. These ASHA's further created awareness among study participants (women above 30 years). A structured questionnaire on knowledge and practice was administered before and after educational intervention by ASHA workers. Clinical Breast Examination (CBE) camps were held for women at high risk for breast cancer who were referred to the Division of Breast Surgery, AIIMS Rishikesh, for further management. RESULT: One thousand sixty-one females participated in health education sessions by ASHAs. There was an improvement in knowledge and practice regarding Breast Self-examination after health education intervention. A low prevalence of risk factors for breast cancer was found among attendees of the CBE camp. 3.2% of participants had abnormalities on breast examination needing further workup. CONCLUSION: In the pre-test assessment, we found a low awareness and practice regarding breast cancer which increased significantly among women after behavioral change intervention. The prevalence of risk factors for breast cancer was very low. Trained community health workers were found to be effective in raising awareness, selective screening, and prompt referral.

Axillary vascular malformation visualized on mammogram: A case report.

Chest wall lesions can mimic masses on mammograms and can cause diagnostic difficulty in interpretation. Here, we report a case of an axillary and retro-pectoral vascular malformation visualized on mammography in a 67-year-old patient presenting with fullness in the right axilla and right supraclavicular region. Mammography, ultrasonography (US), and computed tomography (CT) angiography of the patient were done to make the final diagnosis.

Utility of Axillary Reverse Mapping (ARM) and Incidence of Metastasis in Arm Draining Lymph Nodes in Patients with Breast Cancer.

Objective Lymphedema of the upper limb is the most common complication in patients with breast cancer, who require axillary lymph node (LN) dissection. Proposition of identifying upper limb draining LN and preserving it, during axillary dissection can reduce significant postoperative morbidity, but it has the risk of inadequate oncological resection. This study was planned to find out metastatic rate in axillary reverse mapping (ARM) nodes in our population. Materials and Methods Lymphoscintigraphy (LSG) was performed using intradermal injection of 99m Tc Sulfur Colloid into ipsilateral second and third interdigital web spaces of hand in patients with breast cancer. Planar, single-photon emission computed tomography-computed tomography images were acquired followed by intraoperative localization of arm draining LNs using Gamma Probe. All identified ARM nodes were dissected and sent for histopathological examination to confirm metastatic involvement. Results Twenty eligible patients were prospectively analyzed. The identification rate of arm draining LN with LSG was 90% (18/20). Among 14 eligible patients included in the study, ARM node metastasis was seen in two patients. A total of 64 ARM nodes were dissected from 14 patients, 4/64 nodes (2 patients) were positive for metastases (6.25%). Of the six patients excluded from the study, in 1 patient ARM node could not be identified on Gamma Probe, in two cases, it could not be retrieved surgically, in next two cases ARM could not be identified on LSG and remaining one case was removed because of previous surgical intervention. Conclusion In the current study, LSG showed the identification rate of 90% for ARM nodes in patients with carcinoma breast and metastatic involvement was seen in 6.25% (4/64) of these nodes in 2/14 (14.2%) patients, which is in agreement with previously published data. Oncological safety of preserving ARM nodes needs to be evaluated in the larger population.

Study of Diagnostic Delay among Symptomatic Breast Cancer Patients in Northern India: A Mixed-Methods Analysis from a Dedicated Breast Cancer Centre.

OBJECTIVE: We conducted this study to understand the factors that contribute to the delay in diagnosis of symptomatic breast cancer patients. METHODOLOGY: We did a prospective analytical study with both quantitative and qualitative components over 14 months. The total delay in diagnosis of breast cancer from first symptom onset was defined as diagnostic delay. Presentation delay was defined as the time duration between the first symptom and the first visit to a health care provider. Provider delay was defined as the time duration between the presentation to a health care provider and the final diagnosis. Three hundred female breast cancer patients with a diagnostic delay of at least 3 months were interviewed using a pre-tested semi-structured questionnaire. RESULTS: We found that more than 50% of patients with delayed presentation were between 30-50 years of age. Painless breast lump was the most common initial symptom. More than 70% of patients presented with locally advanced and metastatic disease. The patient-related delay was more common than provider delay. Breast cancer awareness (p = 0.040) and reasons for delay (p = 0.014) were found to significantly influence the delay. More than 70% of patients reported their symptoms to male members of their families. CONCLUSION: Breast cancer awareness is the single most important determinant influencing diagnostic delay among symptomatic patients.

Keratin cyst as a diagnostic pitfall in aspiration cytology of phyllodes tumor.

BACKGROUND: Phyllodes tumor (PT) is a fibroepithelial lesion of breast known for presence of a heterogenous stroma. However occurrence of a keratin cyst within PT is a rare incidence. An inadequate sampling during fine needle aspiration (FNA) of such lesions may result in an erroneous cytological diagnosis. CASE REPORT: In the present case, ultrasound guided FNA smears from the breast lump in a 31-year-old lady with a clinical suspicion of malignancy, were repeatedly interpreted as an epidermal inclusion cyst, which was ultimately reported as a borderline PT on mastectomy. CONCLUSION: The case report aims at highlighting the importance of a diligent FNA technique keeping in mind the possibility of the various uncommon lesions especially while dealing with such a heterogenous tumor as phyllodes.

Impact of COVID-19 On Breast Cancer Management: A Radiological Prespective from A Tertiary Centre.

OBJECTIVE: The coronavirus-2019 (COVID-19) pandemic caused delaying breast cancer management, increasing time interval in chemotherapy cycles and surgery. This has implications on radiological manifestation of cancer. Further, we evaluated changes observed in mammography. MATERIALS AND METHODS: This case control study was conducted from March 25th, 2020 to August 15th, 2020 at the Integrated Breast Care Centre, All India Institute of Medical Science Rishikesh (AIIMS), Rishikesh. Sonomammography was performed on follow-up patients who were on chemotherapy and were scheduled for surgery. Moreover, duration of delay from the last neoadjuvant chemotherapy (NACT) cycle was recorded. Similar data in the pre-COVID-19 period from November 4th, 2019 to March 24th, 2020 was compared with post-COVID-19 data and was analyzed by SPSS Version 23. RESULTS: The study included 54 patients who presented between March 25th, 2020 and August 15th, 2020. Furthermore, the delay in NACT cycles has been shown to be associated with disease progression (p = 0.045). Subgroup analysis of treatment duration with various parameters revealed significant correlation between size, appearance of ulceration, and response evaluation (p<0.05). However, no significant association was found between duration of delay and the histological subtype of lesion (p>0.05). A substantial difference was seen in the evaluation of NACT response in pre- and post-COVID-19 time, with partial response (n = 39, 58.24%) seen as the most common response in pre-COVID-19 time and progressive disease (n = 28, 51.9%) as the most common response in post-COVID-19 time (p<0.001). CONCLUSION: The coronavirus pandemic has severe impact on breast cancer management. A delay in NACT causes progression in cancer. This can be seen in ultrasound and mammogram.

Accuracy of Breast Fine-Needle Aspiration Biopsy Using the International Academy of Cytology Yokohama System in Clinico-Radiologically Indeterminate Lesions: Initial Findings Demonstrating Value in Lesions of Low Suspicion of Malignancy.

BACKGROUND: Fine-needle aspiration biopsy (FNAB) in breast lesions offers accurate results in differentiating benign and malignant lesions. However, its role is unclear when core-needle biopsy (CNB) is available, the latter providing additional information regarding tumor grade, invasion, and hormone receptor status in malignant lesions. In benign breast lesions, especially in BIRADS category 4a and 4b, FNAB, and CNB provide similar pathological information, whereby FNAB may serve as a more rapid and cost-effective investigation. The study was planned to reevaluate the diagnostic accuracy of FNAB in BIRADS category 4a, 4b, and 4c lesions. MATERIALS AND METHODS: FNAB and biopsy reports of all patients with breast lesions sent between September 1, 2018, and November 30, 2020, were collected and the International Academy of Cytology (IAC) Yokohama category and BIRADS score were recorded for each case. The rate of malignancy and the accuracy of FNAB in diagnosing malignancy were calculated for each BIRADS 4a, 4b, and 4c subgroup. RESULTS: A total of 249 cases of BIRADS 4 lesions had corresponding cytology and histopathology diagnoses. FNAB showed high diagnostic accuracy in all BIRADS groups. A benign categorization was associated with a very low number of false-negative diagnoses, especially in BIRADS 4a lesions. CONCLUSION: The study reconfirms the excellent accuracy of breast FNAB using the IAC Yokohama system in diagnosing breast malignancies. Furthermore, BIRADS 4a lesions found to be belonging to the cytological benign category may be excluded from CRB and kept on clinical follow-up.

Prospective evaluation of accuracy of fine-needle aspiration biopsy for breast lesions using the International Academy of Cytology Yokohama System for reporting breast cytopathology.

BACKGROUND: Classification of breast lesions into different cytological groups can accurately be done using the International Academy of Cytology (IAC) Yokohama System for reporting breast cytopathology. Fine needle aspiration biopsy (FNAB) of breast lesions has been considered to be the primary investigation in detecting breast cancers, especially in low-cost settings. The main objective of this study was to prospectively re-confirm the diagnostic accuracy of breast FNAB using the IAC Yokohama system. Additionally, separate secondary subgroup analysis was done to confirm the accuracy of breast FNAB excluding lymph-node positive and lymphadenopathy positive tumors. MATERIAL AND METHODS: A prospective study was done on patients undergoing biopsy of breast lesions between September 01, 2019 and November 30, 2020 (519 biopsies on 487 unique patients). Of these 519 histopathology biopsies, 505 had corresponding FNAB report of the same site. The FNAB was reported using the IAC Yokohama system and the most suitable category was allotted in every case. The rates of malignancy for each category and the accuracy of breast FNAB in diagnosing malignancy were calculated. RESULTS: Of the total 487 patients, 120 cases were benign on histology, while 367 were malignant. The rates of malignancy in benign, atypical, suspicious and malignant categories were 5%, 25%, 71%, and 99.7%, respectively. The diagnostic accuracy of atypical, suspicious and malignant categories was calculated as 90.1%, 95.2%, and 93.3%, respectively. CONCLUSION: The high diagnostic accuracy for each BIRADS category suggest excellent accuracy for Breast FNAB using the IAC Yokohama system.

Surgical Diseases Management during COVID-19 Crisis at a Tertiary Care Hospital of India: Our Institutional Strategy.

Introduction In response to the national coronavirus disease 2019 (COVID-19) pandemic, all hospitals and medical institutes gave priority to COVID-19 screening and to the management of patients who required hospitalization for COVID-19 infection. Surgical departments postponed all elective operative procedures and provided only essential surgical care to patients who presented with acute surgical conditions or suspected malignancy. Ample literature has emerged during this pandemic regarding the guidelines for safe surgical care. We report our experience during the lockdown period including the surgical procedures performed, the perioperative care provided, and the specific precautions implemented in response to the COVID-19 crisis. Materials and Methods We extracted patient clinical data from the medical records of all surgical patients admitted to our tertiary care hospital between the March 24th, 2020 and May 31st, 2020. Data collected included: patient demographics, surgical diagnoses, surgical procedures, nonoperative management, and patient outcomes. Results Seventy-seven patients were included in this report: 23 patients were managed medically, 28 patients underwent a radiologic intervention, and 23 patients required an operative procedure. In total eight of the 77 patients died due to ongoing sepsis, multiorgan failure, or advanced malignancy. Conclusion During the COVID-19 lockdown period, our surgical team performed many lifesaving surgical procedures and appropriately selected cancer operations. We implemented and standardized essential perioperative measures to reduce the spread of COVID-19 infection. When the lockdown measures were phased out a large number of patients remained in need of delayed elective and semi-elective operative treatment. Hospitals, medical institutes, and surgical leadership must adjust their priorities, foster stewardship of limited surgical care resources, and rapidly implement effective strategies to assure perioperative safety for both patients and operating room staff during periods of crisis.

Accuracy of the International Academy of Cytology Yokohama system of breast cytology reporting for fine needle aspiration biopsy of the breast in a dedicated breast care setting.

BACKGROUND: The International Academy of Cytology (IAC) Yokohama system is a recently proposed system for reporting breast cytology by fine needle aspiration biopsies (FNAB). Multiple studies are needed to confirm the risk of malignancy (ROM) of the various reporting categories of this system. The present article studies the accuracy of the IAC Yokohama system in our center. METHODS: Over a period of 1 year (September 2018-August 2019), all cases of breast masses assessed by FNAB and histological correlation were studied retrospectively. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) and overall accuracy of the IAC Yokohama system for diagnosing malignancy were assessed. The rates of malignancy (ROM) of each diagnostic category were also estimated. RESULTS: Three hundred and twenty-one FNABs had cyto-histological correlation. The percent sensitivity (with 95% Confidence Intervals) when the atypical, suspicious of malignancy and the malignant categories were regarded as positive for malignancy were 98.2% [95.5%, 99.5%], 96.0% [92.5%, 98.2%], and 86.7% [81.5%, 90.8%] respectively. The percent specificity (with 95% Confidence intervals) for the same categories in the same order were 59.5% [47.4%, 70.7%], 91.9% [83.2%, 97.0%], and 100% [95.1%, 100%] respectively. The area under curve (AUC) for diagnosing malignancy was 0.981[0.963, 0.993]. The ROM for the benign, atypical, suspicious of malignancy and malignant category were 8.3% [2.3%, 20.0%], 17.2% [5.8%, 35.8%], 77.8% [57.7%, 91.4%], and 100% [98.1%, 100%] respectively. CONCLUSION: The IAC Yokohama system is suitable for accurately reporting breast lesions on FNAB.

A randomized single-blinded, parallel-arm group feasibility trial evaluating role of pectoral nerve block on serum vascular endothelial growth factor levels in patients undergoing unilateral modified radical mastectomy.

Metastatic breast cancer cells carry adult and neonatal variants of NaV1.5 voltage-gated activated Na+ channels involved in cell invasion. We hypothesize that instilling lignocaine near the surgical field to anesthetize the pectoral nerves for analgesia will decrease angiogenesis by blocking voltage-gated activated Na+ channels. Twenty patients undergoing unilateral modified radical mastectomy were randomized in a single-blinded, parallel-arm group feasibility pilot study in two groups. In Group I a catheter was placed between the pectoralis major and minor muscle under direct vision before skin closure. Ten milliliters of 2% lignocaine was given as an initial bolus followed by 10 mL of 2% lignocaine every 8 hours up to 24 hours. Group II did not receive any regional block. Primary measure outcomes were pre and postoperative changes in levels of vascular endothelial growth factor. Secondary outcomes were postoperative pain scores and total rescue analgesia used. Nine patients in each group were analyzed. Baseline demographic data of all females were similar with respect to age, body mass, height and duration of anesthesia. Postoperative mean serum levels of vascular endothelial growth factor were decreased by 46.60% from baseline in Group I, while were increased by 84.27% as compared to preoperative values in Group II. Postoperative average pain scores were less in Group I. Postoperative rescue analgesia in 24 hours in Group I was lower than that in Group II. There was no postoperative adverse event related to catheter or lignocaine administration at given doses. Instilling lignocaine to block pectoral nerves provides better postoperative analgesia and decreases a marker of angiogenesis. The study protocol was approved by the Institutional Ethical Committee of the Tertiary Centre (All India Institute of Medical Sciences Rishikesh India) (No. AIIMS/IEC/19/1002) on August 9, 2019, and the larger expansion trial was prospectively registered on Clinical Trial Registry India (No. CTRI/2020/01/022784) on January 15, 2020.

Invasive ductal carcinoma of breast and squamous cell carcinoma of anterior chest wall-A rare collision.

Collision tumors are two distinct neoplasms seen together in same anatomic site. Management of such rare entity still lacks standardization with unknown prognosis. Here we are presenting one such rare case of invasive ductal carcinoma of breast and squamous cell carcinoma of anterior chest wall in a 31-year-old lady.

Pemphigus in Sarcomatoid Renal Cell Carcinoma: A Rare Paraneoplastic Manifestation.

Renal cell carcinoma with sarcomatoid features is a rare presentation with a 5% incidence. Sarcomatoid renal cell carcinoma is usually associated with poor prognosis. It commonly metastasizes to the lungs, bones, and liver. Dermatological manifestation with paraneoplastic syndrome is extremely rare. Pathogenesis of PNP in renal cell carcinoma is not cleat; till date, however, few literature suggest antibodies against a group plakin family which plays a key role in intermediate filament attachment in RCC. We present PNP in a 64-year-old female associated with renal cell carcinoma.