Phyllodes Tumors of the Breast-Experience in a Tertiary Care Center.

Phyllodes tumors (PTs) are rare neoplasms of the breast that are a challenge in clinical practice. Though mostly benign, they are notorious for local recurrence, requiring adjuvant treatments. This study was planned to report the clinicopathological features and outcomes of patients with PT treated at our center. Details of all patients who underwent surgery for PT in the last 6 years (December 2017-December 2023) were obtained from our prospectively maintained database. The demographic, clinical, radiological, pathological, and follow-up details were recorded and analyzed. Statistical analyses were carried out with Jamovi version 2.3.18. Out of 61 suspected PTs by triple assessment, 9 were excluded due to a non-phyllodes diagnosis on histopathology. We included 52 women with a mean age of 38.2 ± 11.0 years, most of whom were premenopausal (57.7%). BI-RADS 4 was the most common finding on radiological assessment (65.4%). Core needle biopsy (CNB) was the most frequently employed modality for histological diagnosis preoperatively (65.4% of cases). Wide local excisions (WLE) and mastectomies were done in 63.5% and 36.5% of patients, respectively. Benign, borderline, and malignant phyllodes constituted 67.3%, 15.4%, and 17.3% of tumors, respectively. Patients undergoing breast conservation surgery (BCS) had a significantly smaller mean tumor diameter than those who underwent a mastectomy (p < 0.001). Overall, the margin positivity rate was 34.6%. Patients undergoing mastectomy developed more local recurrence compared to WLE, although the difference was not significant (p = 0.400). The outcome following surgical excisions of large PTs in terms of margin positivity and local recurrence is the same, irrespective of whether BCS or mastectomy is done. A negative pathological margin width of > 1 mm appears acceptable. Malignant phyllodes with positive margins are associated with a higher rate of recurrence but positive margins in patients with other subtypes may not translate into recurrence, at least in the short term.

Massive Ovarian Mucinous Cystadenoma Complicating Term Birth.

Usually, symptomatic ovarian cysts in pregnancy require surgical removal in the second trimester. However, occasionally, large ovarian cysts may be encountered in the third trimester, which might hinder normal vaginal delivery. Herein, we present one such case to highlight the challenges of managing a large ovarian cyst in a full-term pregnancy.

Sentinel lymph node biopsy in early breast carcinoma using fluorescein sodium and methylene blue dye: A validation study.

The availability of radioisotopes for sentinel lymph node biopsy (SLNB) in breast carcinoma is limited in low- and middle-income countries and thus the need for other reliable tracers exists. We aimed to validate the effectiveness of fluorescein sodium (FS) together with methylene blue dye (MBD) for patients with node-negative early breast carcinoma in a prospective cross-sectional study. Patients underwent SLNB using FS and MBD followed by axillary dissection to validate results. Sentinel lymph node (SLN) identification rate and false negative rate were assessed for all three tracers/combinations (MBD, FS, and MBD + FS). We concluded that SLNB using a combination of FS and MBD has an acceptable rate of SLN identification but the addition of FS provided no additional benefit.

Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial.

BACKGROUND: Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo. PATIENT AND METHODS: Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared. RESULTS: The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar. CONCLUSIONS: Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.

Laparoscopic-assisted neo-cervico-vaginal anastomosis and neo-vagina creation in congenital atresia: A retrospective study measuring the outcome and success.

Cervico-vaginal agenesis is a developmental disorder classified as a Mullerian duct anomaly. STUDY OBJECTIVE: We aimed to study the surgical outcomes of vaginoplasty and laparoscopic-assisted cervical-vaginoplasty carried out using our set-up from June 2016 to December 2022. Additionally, we measured the success of our modified laparoscopy-assisted neo-cervical creation. DESIGN: A retrospective study. SETTING: The study was conducted in a tertiary care center and included all patients who underwent vaginoplasty and neo-cervico-vaginal creation using the rail-road method. PATIENTS: A total of 33 patients were followed-up meticulously and their outcomes were noted. The study was retrospective and largely depended on patient compliance during follow-up. INTERVENTION: Of the 33 patients, 22 underwent vaginoplasty (McIndoe technique) and 11 underwent neo-cervico-vaginoplasty (rail-road method using both open and laparoscopic methods). MEASUREMENTS AND MAIN RESULTS: The most common presentation was primary amenorrhea (cyclic abdominal pain with primary amenorrhea) and urinary retention. Four patients underwent hysteroscopy-guided hematometra drainage and none underwent hysterectomy. The average vaginal length measured during the follow-up was 5.2 ± 1.90 cm. Significant symptom relief was observed. Longest follow-up duration was 4.7 years with a mean duration of 210 (180) days. CONCLUSION: Although the procedure is strenuous, postoperative results showed satisfactory outcomes in improving the quality of life of patients. With expertise in the technique, the associated comorbidity is reduced, which provides relief for the patients.

Breast carcinoma presenting with upper limb lymphedema - A rare case.

Lymphedema (LE) in a breast cancer patient usually results from axillary lymph node dissection, sentinel lymph node biopsy, and/or axillary radiotherapy. Although lymphatic obstruction and consequent LE can occur due to axillary lymph node involvement, such presentation in breast cancer patients has rarely been reported. This report describes the case of a 50-year-old lady with right breast carcinoma who presented with right upper limb lymphedema. Surprisingly, she did not have any bulky axillary lymphadenopathy that could have accounted for lymphedema of the upper limb, but a suspicious breast mass was present on clinical examination. Diagnosis of breast cancer on clinical examination can be challenging in such patients due to breast edema and careful imaging of the breast and axilla with appropriate imaging tools (mammogram, ultrasound, MRI, PET mammography) should be resorted to before excluding malignancy. Lymphoscintigraphy confirmed the findings of lymphedema in the right upper limb and revealed uptake in the epitrochlear lymph nodes of the contralateral limb suggesting that she might had pre-existing widespread "subclinical lymphedema" which presented as "clinical lymphedema" in right upper limb after axillary lymph node/lymphatic involvement by right breast carcinoma.

Multimodal Intraoperative Neurophysiological Monitoring in Cranial and Spinal Tumour Surgeries: A Descriptive Observational Study.

Intraoperative neurophysiological monitoring (IONM) involves monitoring the functional integrity of critical brain regions and pathways as well as identifying and preserving functionally viable neural tissues (mapping) during surgery using electrophysiological techniques. Multimodality combines various neurophysiological techniques to optimise diagnostic effectiveness and to improve the outcomes of the surgeries. The present study is a case series with comprehensive and illustrative descriptions of the neurophysiological changes in five neuromonitored cases of cranial and spinal cord tumour surgeries conducted with a multimodal approach. The cases were monitored with somatosensory evoked potentials (SSEP), transcranial motor evoked potentials (TcMEP), and both free run and triggered electromyography (fEMG and tEMG). No false negative outcomes were identified in the cases studied as there was an association of absence of change in SSEP and TcMEP both, with no neurological deficit postoperatively. Two cases were identified as having true positive neuromonitoring alerts. No false positive alerts were found in any case. Multimodal monitoring using SSEP, TcMEP, and EMG (fEMG and tEMG) in cranial and spinal tumour surgeries can improve performance with fewer false-negative and false-positive results. Neuromonitoring approaches used in combination can provide reliable information regarding postoperative neurological outcomes.

Soft Tissue and Lower Limb Muscle Metastases from Breast Carcinoma: An Unreported Entity.

Soft tissue metastasis from carcinoma breast is rare, and still rarer is metastasis to skeletal muscles. So far, soft tissue metastasis from breast carcinoma has been reported only in a small number of case series and case reports. To the best of our knowledge, no case of breast cancer metastasizing to the lower limb muscles has been reported. It is important to differentiate soft tissue metastasis from primary soft tissue malignancy, as the management and prognosis of these differ markedly. Here, we present a case of breast cancer metastasizing to the soft tissue at multiple sites including the right thigh muscles.

Overcoming Obstacles During Caesarean Section with a Fibroid in the Uterus, from Diagnosis to Decision: A Case Series.

BACKGROUND: We regularly face pregnancy with fibroid since pregnancy at advanced ages has been more prevalent and the prevalence of lower segment caesarean section (LSCS) has also increased over the previous three decades. Myomectomy with cesarean section has historically been avoided because of the danger of haemorrhage, but obstetricians now place more emphasis on it. Since fibroids can range widely in terms of location, size, and patient features, the intervention should be individualized. Under this article, we, therefore, provide a case series of seven pregnant women with uterine myomas who had delivery via LSCS. METHOD: Seven pregnant patients who had uterine fibroid and undergone cesarean section were enrolled in this observational study done over the period of one year with consent and after taking ethical approval.  Results: The mean age was 27.7 years. Three of the cases were primigravida, while the remainder were multigravida. One patient had red degeneration and was hospitalized with abdominal discomfort at 29 weeks gestation. Four patients had a solitary fibroid, while the three had numerous. The biggest myoma size was 8×7 cm, while the smallest was 5×5 cm. Due to the presence of the fibroid in the lower segment of the uterus, three patients had a caesarean myomectomy, while in rest four cases it was not done. During cesarean myomectomy, two of them had uterine artery ligation to limit the moderate intraoperative haemorrhage. CONCLUSION: If the patient is wisely chosen and the surgeon has the experience, a caesarean myomectomy can be performed safely and successfully during LSCS, especially if located in the lower uterine segment (LUS).

Accuracy of Serum Parathyroid Hormone Measured on the Early Morning of the First Postoperative Day in Predicting Clinically Significant Post-Total Thyroidectomy Hypocalcemia.

INTRODUCTION: Clinical hypocalcemia (CH) following total thyroidectomy (TT) is a potentially life-threatening condition if left untreated. This study aimed at evaluating the accuracy of parathyroid hormone (PTH) measured in the early morning of the first postoperative day (POD-1) in predicting CH, and determining the cutoff values of PTH that can predict the development of CH. METHODS: We performed a retrospective review of patients undergoing TT between February 2018 and July 2022. Serum PTH, calcium, and albumin levels were measured on morning (6-8 AM) of postoperative day one (POD-1), and serum calcium level was measured from POD-2 onwards. We performed ROC curve analysis to determine the accuracy of PTH in predicting postoperative CH, and cutoff values of PTH to predict CH. RESULTS: Ninety-one patients, 52 (57.1%) with benign and 39 (42.9%) with malignant goiter were included. The incidence of biochemical, and clinical hypocalcemia was 24.2% and 30.8%, respectively. In our study serum, PTH measured in the early morning of first postoperative day following TT was found to have good accuracy (AUC = .88) in predicting CH. A PTH value of ≥27.15 pg/mL was found to have a 96.4% sensitivity in ruling out CH, while a serum PTH value <10.65 pg/mL had a specificity of 95.2% in predicting CH. DISCUSSION: Patients with a serum PTH value of ≥27.15 pg/mL can be discharged without any supplements, those with PTH <10.65 pg/mL should be started on calcium and calcitriol supplements, while patients having PTH values between 10.65 and 27.15 pg/mL should be monitored for the development of signs and/or symptoms of hypocalcemia.

Complete Laparoscopic Ovarian Cystectomy of Giant Ovarian Serous Cystadenoma.

We report here a case of an unmarried teenage girl with a 19-kg giant ovarian cystic tumors of size 37cm×31cm×22cm, which was presumably benign on imaging and with negative tumor markers; treated by complete laparoscopic ovarian cystectomy following decompression and the patient was discharged the next day.

The Appropriate Criteria in Patients Selection for Myomectomy in the Era of Minimally Invasive Surgery: A Case Report.

Background: Myoma is the most common benign monoclonal neoplasm of the uterus with increased frequency during reproductive years of women. Case Presentation: A twenty two year old female presented with abdomen lump, dysmenorrhoea, and heavy menstrual bleeding. Multiple myomas were diagnosed based on clinical and radiological findings. Abdominal myomectomy was performed and 75 myomas were enucleated followed by reconstruction of uterus. The second case was a 28 year old married woman presented with heavy menstrual bleeding and dysmenorrhoea. Ultrasound reported single posterior wall myoma of 8×6.3×5.8 cm in size. Laparoscopic myomectomy was performed. At follow-up visit, both cases were completely free of any symptoms. Conclusion: Myomectomy is a feasible and safe option and a uterine preserving surgery even in the presence of multiple myomas. Setting appropriate criteria in selecting patients for abdominal myomectomy rather than MIS is essential to avoid conversion and associated morbidity.

Acute inflammatory response to multiple chemotherapy regimen in breast carcinoma: An unreported entity1.

Increased utilization of chemotherapy in breast cancer patients has led to improved survival outcomes but it has also resulted in rising incidence of adverse effects. Occurrence of new/unreported side effect poses challenge in front of clinicians. We report the case of a 53-year lady with locally advanced, hormone receptor-positive, and human epidermal growth factor-2 (HER-2) negative right breast carcinoma. She was started on neoadjuvant chemotherapy (NACT) (doxorubicin and cyclophosphamide), to facilitate breast-conserving surgery. She developed an inflammatory reaction involving the affected breast after each of three cycles of NACT (2 cycles of doxorubicin & cyclophosphamide, and 1 cycle of docetaxel). Infectious causes and disease progression were ruled out. She was then prescribed hormone therapy but the disease progressed after three months of therapy and the patient had to be subjected to modified radical mastectomy (MRM). She then received adjuvant radiotherapy and is currently doing well on second-line hormone therapy.

Diffuse Leiomyomatosis of the Uterus: A Diagnostic Enigma.

We present a case of diffuse uterine leiomyomatosis in a 38-year-old nulliparous female presenting with abdominal distension and infertility, which is very rarely reported and commonly misdiagnosed. Magnetic resonance imaging (MRI) of the abdomen and pelvis showed an enlarged uterus of size 25 × 20 ×13 cm with a few fibroids in the lower uterine segment and pressure effects on the ureter, causing hydroureteronephrosis. The fundal region and upper uterine segment were extensively thickened with a mildly thinned-out junctional zone. A total abdominal hysterectomy was performed, and the diagnosis of diffuse leiomyomatosis of the uterus was confirmed on histopathological examination. The post-operative period was complicated by hypovolemic shock, which was managed by transfusion of multiple units of blood, blood components, and hemostatics. On the ninth post-operative day, the patient gained full recovery and was discharged.

Evaluation of the Effects of Polidocanol Injection in the Treatment of Temporomandibular Joint Hypermobility - A Prospective Study.

Introduction: Sclerosing agents have been used for temporomandibular joint (TMJ) hypermobility since decades, some of which are ethanolamine oleate, and OK-432, sodium psylliate (sylnasol), but there are no studies on the usage of polidocanol - a well-known sclerosing agent which does not have much side effects and is inexpensive. Hence, this study evaluates the effect of polidocanol injection in the treatment of TMJ hypermobility. Methodology: This was a prospective observational study in which patients with chronic TMJ hypermobility were included. Out of the 44 patients who had symptoms of clicking and pain of the TMJ, 28 were diagnosed as internal derangement of the TMJ. The final analysis included 15 patients in whom multiple injections of polidocanol were given on the basis of post-operative parameters. The sample size was calculated based on a significance level of 0.05 and a power of 80%. Results: Overall, a success rate of 86.6% (13/15) was encountered at the end of three months, with seven patients not reporting any further episodes of dislocation after one injection and six patients not reporting any episode of dislocation after two injections. Discussion: Polidocanol sclerotherapy can be used as a treatment modality for chronic recurrent dislocation of the TMJ, rather than opting for more invasive procedures for the same.

Development and validation of sonological classification and scoring system for uterine adenomyosis: A pilot study.

Background: Adenomyosis is a common disorder in women of reproductive age. The gold standard for diagnosis is histopathological examination of hysterectomy specimen. However, only a small percentage of women undergo surgery as treatment is primarily hormonal. Non-invasive methods of diagnosis include transvaginal sonography and magnetic resonance imaging. Patient management in adenomyosis is often based on ultrasonographic diagnosis alone, highlighting the importance of a uniform, reproducible, clinically relevant and validated sonological classification and scoring system. Although a few investigators have proposed classification and scoring system for diagnosis of adenomyosis, none of those have been validated yet. This study aimed to propose and validate a new sonological classification and scoring system for adenomyosis. Methods: This was a prospective observational pilot study. A new sonological classification and scoring system of adenomyosis was proposed based on topography, type, size and extent, which was validated by comparing the sonological reporting with histopathological reporting. The main outcome measures that were measured were rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist; and diagnostic accuracy of the sonological classification of adenomyosis. Results: This pilot study included 30 women who underwent hysterectomy over a time period of one year with ultrasonographic diagnosis of adenomyosis. The rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist showed substantial agreement (0.703) for topography and almost perfect agreement for type (0.896), extent (0.892) and size (0.898). Conclusions: Our newly proposed sonological classification and scoring system for adenomyosis is valid and can be used for clinical application in interpersonal communication between clinicians, to prognosticate patients about the disease severity, to assess the candidates for surgical management and in further studies to correlate with symptoms severity and effectiveness of medical therapies.

First Comprehensive Report of Clinicopathological Profile of Breast Cancer from Bihar, India.

Only a few countries of the world have a population more than Bihar, but due to the lack of a cancer registry, authentic research, and publications, data regarding the clinicopathological characteristics of breast cancer patients from this state are scarce. The present study was aimed to report the clinicopathological characteristics of breast cancer patients at a tertiary care center in Bihar, India. This is a retrospective review of a prospectively maintained database of patients of breast cancer treated between January-2018 and March-2020. One hundred fifteen patients with breast carcinoma were included of which 112 (97.4%) were women. The mean age was 47.28 ± 11.62 years and 54.5% of women were postmenopausal. Most patients had a clinical stage of II or III (44.5% each) while 8.7% of patients had stage IV disease. Invasive ductal carcinoma no special type (IDC-NST) was the most common histology (85.2%). The majority of tumors were grade II (55.6%), lymphovascular invasion was seen in 45.6%, and perineural invasion in 18.4%. Estrogen receptor was found in 41.8%, progesterone receptor was positive in 47.3%, and human epidermal growth factor receptor-2 (HER-2/Neu) overexpression was observed in 39.8%. Triple-negative breast cancer was found in 26.2% of patients. The majority underwent mastectomy (71.3%) while breast conservation was done in 26%. All except one patient underwent axillary lymph node dissection for axillary staging. 43.5% patients received neoadjuvant chemotherapy, 52.9% received adjuvant chemotherapy, while 3.5% patients received palliative chemotherapy. The clinicopathological profile of breast cancer patients from Bihar is similar to that reported from other parts of India except for a lower rate of distant metastasis.

Does Tumor Marking Before Neoadjuvant Chemotherapy Helps Achieve Better Outcomes in Patients Undergoing Breast Conservative Surgery? A Systematic Review.

Patients with breast cancer are increasingly being offered breast conserving surgery (BCS) following neoadjuvant chemotherapy (NACT). We aimed to conduct a systematic review to assess the advantage of tumor marking in patients undergoing BCS after NACT. After registering the protocol for a systematic review with PROSPERO, a systematic search was conducted through September 30, 2020, for all studies involving patients undergoing BCS post NACT after tumor marking. Margin status on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. A total of 636 records from Medline/PubMed, 1381 from Embase, and 1422 from Cochrane library were extracted. After screening, 15 articles (1520 patients) were included for data synthesis. For marking, 6 studies used metallic markers and 5 used 125I-radioactive seeds (RSL) followed by skin tattoo and radio-guided occult lesion localization using 99mTc (ROLL) in one study each. Most studies used a single marker at the center except for two (143 patients), who practiced the bracketing technique. Incidence of unsatisfactory margins (positive/close) ranged from 5 to 23.5%. After excluding patients with complete pathological response, the "adjusted unsatisfactory margin" rate was found to be 19.3% (10.4-33%). Overall 20.6 recurrences (locoregional/distant) were reported per 1000 patient-years follow-up. Overall survival (OS) was only reported by one study as 96.6% and 84.7% in patients with and without marker placement (p = .01). Re-excision and secondary mastectomy rates (reported by nine studies) were 7.3% and 5.7% respectively. There is limited evidence that tumor marking before neoadjuvant chemotherapy improves the rate of unsatisfactory margins or survival outcomes in a patient undergoing BCS after NACT.

Canalicular lacerations in a tertiary eye hospital: our experience with monocanalicular stents.

Introduction: Canalicular injury is commonly encountered in lid trauma. A multitude of techniques and stents are available to manage canalicular lacerations. Monocanalicular stents offer a simple, technically easy and cost-effective solution for managing such cases. Objective: This is a retrospective review of the patients presenting with canalicular lacerations to a tertiary eye hospital from January 2014 to September 2017. We evaluated factors like time of surgery, cause of injury, time of stent removal and their association with the surgical outcome. Additionally, we also reviewed the current data available in literature on the exclusive use of monocanalicular stents for the management of all types of canalicular injuries. Methods: Retrospective patient file review. Results: We evaluated 30 cases of canalicular injuries in 30 patients. The majority of our patients were males (24, 80%), and the mean age was 32.11±15.09 (4-59) years. The mode of injury was road traffic accidents (RTA) in 20 (66.7%), assault with sharp edged weapons in 8 (26.7%) and dog bite in 2 (6.6%) cases. The mean time of repair was 17.2±9.37 (6-36) hours after injury and the mean time of stent removal/ extrusion was 3.5±0.99 (0.5-5) months. The cases were divided based on time of repair i.e., within 24 hours (21 cases) or after 24 hours (9 cases) from the onset of injury. The extrusion rates were 14.3% (3) and 44.4% (4) respectively in the two groups. Our overall anatomical success rate was 86.7% and functional success rate of 76.7%. Conclusions: Overall failure rate was 23.3% (7 out of 30). Delay in surgery (>24 hours) and dog bites were associated with a poorer prognosis of canalicular repair using monocanalicular stents. Abbreviations: FDDT = Fluorescein dye disappearance test, SPSS = Statistical Package for Social Sciences, RTA = Road Traffic Accident.