Prospective Study to Evaluate Efficacy of Single Versus Double Drains in Breast Cancer Patients Undergoing Surgery.

Seroma formation is a common sequel following modified radical mastectomy (MRM), which hinders healing, may prolong hospital stay, and cause a delay in adjuvant treatment. Closed suction drains have been used to prevent formation of seroma; however, the use of a single drain in the axilla along with draining the mastectomy flaps and axilla separately remains a topic of debate. This prospective randomized dual-arm study was conducted in the Department of Endocrine Surgery. All female patients with carcinoma breast diagnosed on core tissue biopsy, undergoing modified radical mastectomy, upfront or post neoadjuvant systemic therapy were included. Patients were randomized into two groups. In the first group, a single drain was placed in the axilla whereas in the second group, a drain each was placed below the mastectomy flaps and the axilla. Patients' particulars and the weight of the mass excised along with the operative details were documented. The volume of the drain was recorded daily. The flap drain was removed on postoperative day 5 and the axillary drain was removed when the drain volume was less than 30 mL/24 h for 2 consecutive days. The period of drain placement, volume of drainage, volume of seroma (if formed), and other complications (if any) were recorded. Patients in the single drain group had a significantly earlier drain removal time as compared to those with double drains (p = 0.01). The number of patients in whom seroma formation had occurred was more in the double drain group, but the difference was not significant. The average volume of aspirated seroma fluid was insignificantly more in the single drain group. The only other complication noticed was flap necrosis-in 5% patients of the double drain group. Total volume of drainage (p < 0.0001) and type of drain (p = 0.0208) were associated with higher rates of seroma formation, whereas BMI (p = 0.0516), weight of excised breast mass (p = 0.407), and age (p = 0.6379) were not associated with the rate of seroma formation. Outcomes in terms of drain volume or seroma formation were statistically indifferent between the two groups. Still, use of only a single axillary drain should be promoted, keeping in mind the earlier drain removal period, better patient compliance, and reduced hospital stay.

Pathological Complete Response as Outcome Modifier in Breast Cancer Patients and Brain Metastasis.

Breast cancer with brain metastases (BCBM) has dreadful outcomes. Various factors influencing outcomes are age, receptors status, number of distant metastases, performance status, leptomeningeal metastasis, chemotherapies, and whole brain radiation dose. This study aimed to find outcome-modifying factors in BCBM. Clinical, demographic, subtype, and pathological response of primary brain imaging characteristics of BCBM patients were correlated with brain metastasis-free interval and survival after brain metastasis was studied from January 2020 to March 2022. Triple-negative breast cancer (TNBC) patients had the earliest presentation for brain metastases (mean 45.4 years) vs luminal B (mean 57.93 years). Both brain metastasis-free interval (BMFI) and brain metastasis overall survival (BMOS) were maximum in HER2-positive subtype (mean 22.8 and 11.55 months) and least in TNBC patients (mean 9.8 and 2.12 months), respectively. Low-graded prognosis assessment (GPA) score and leptomeningeal metastasis were associated with the worst outcomes. BMFI and BMOS in patients with pathological complete response (PCR) were at 28.5 and 15.1 months, in partial response were 18.5 and 7.66 months, and with stable or progressive disease were 11 and 1.36 months, respectively. In the present study, PCR was the only modifiable parameter that changed breast cancer outcomes with brain metastasis and leptomeningeal metastasis was associated with the worst outcomes. Our study favors that PCR has prognostic importance.

Effect of Thyroidectomy on Tracheal Remodeling and Airway Physiology in Apparently Asymptomatic Patients with Goiter: A Prospective Study.

BACKGROUND: Tracheal airflow limitation is frequently reported in patients with goiter but is severely underestimated, and studies on how goiter and its treatment affect trachea are scarce. Moreover, the choice of the optimal treatment for individual patient with asymptomatic goiter is not straightforward. Therefore, in this study we aim to investigate the effect of goiter and subsequent thyroidectomy on tracheal anatomy and change in airflow in asymptomatic patient with goiter. METHODS: Seventy patients undergoing total/hemithyroidectomy (TT/HT) from Feb 2020 to Feb 2021 satisfying inclusion criteria were enrolled in the study. Neck radiograph (NR) and forced spirometry (FS) were performed preoperatively and on postoperative day 10 and 6 weeks and 3 months. RESULTS: Out of 70 patients, 84.3% patients were female, and mean duration and weight of goiter were 54.7 months and 72.21 gm, respectively. Of 70 patients, 57 were of benign pathology. Significant improvement in tracheal compression with moderate improvement in deviation was observed after surgery. Preoperative spirometry showed significant reduction in almost all parameters. After surgery, a weak improvement was observed at postoperative day 10 and 6 weeks; however, significant improvement in FEV1, PEFR, FEV1/FEV0.5, and FEF50%/FIF50% was observed at postoperative 3 months. Patient with right sided and those with ≥ 8 mm deviation were associated with poorer pulmonary function. Weak correlation was observed between neck NR and spirometry parameters. Weight of the thyroid gland significantly correlated with ratio of MVV/FEV1. CONCLUSION: Patients with asymptomatic goiter can have significant abnormal changes in airflow as evidenced by FS and NR. Thyroidectomy is followed by gradual restoration of tracheal deviation and compression with significant improvement in pulmonary airflow.

Clinicopathologic Correlation of CD44 + /CD24 - Expression in Breast Cancer: a Report from Tertiary Care Medical University in India.

CD44 + /CD24 - phenotype has been associated with stem cell-like characteristics with enhanced invasive properties, radiation resistance, and with distinct genetic profiles suggesting a correlation to adverse prognosis in western literature. The aim of this study was to study CD44 + /CD24 - phenotype as an adverse prognostic marker in Indian breast cancer patients. N = 61 breast cancer patients included in a tertiary care facility in India were evaluated for receptor studies (estrogen receptor ER, progesterone receptor PR, Herceptin antibody Her2 neu receptor, CD44 & CD24 stem cell markers). CD44 + /CD24 - phenotype was statistically related to adverse factors like estrogen and progesterone receptors non-expression, her 2 neu expression, and triple-negative breast cancer. Of the 39 patients with ER-ve status, 33 (84.6%) were found to have CD44 + /CD24 - phenotype and 82.5% of all the CD 44 + /CD24 - patients were ER negative (p = 0.001). Thirty-four (75.5%) of the PR-ve patients showed the CD44 + /CD24 - phenotype, and of all the CD 44 + /CD24 - patients, 85% of were PR negative (p = 0.006). Thirty-six (75%) of Her-2-Neu + ve were CD44 + /CD24 - . Approximately 90% of the Her 2 Neu patients expressed CD44 + /CD24 - and 76.9% of all the triple-negative patients were found to be CD44 + /CD24 - expression (p = 0.001). CD44 + /CD24 - had a significant association with adverse prognostic factors like stage of disease, hormonal receptor status, and molecular subtypes in Indian breast cancer patients like the Western data.

Revisiting Combination Chemotherapy as a Single Modality Palliative Therapy for Advanced Anaplastic Thyroid Carcinoma-a Single Institution Experience.

Anaplastic thyroid carcinoma (ATC) is an aggressive malignancy with dismal outcome especially in metastatic setting. Consensus for ideal treatment of advanced and metastatic ATC remains elusive. This study aimed to analyze the impact of palliative chemotherapy versus supportive care on overall survival in patients with metastatic anaplastic thyroid carcinoma. Patients diagnosed with ATC between the period January 2018 and December 2019 were prospectively followed. The patients opting for palliative chemotherapy received 3 weekly Paclitaxel (175 mg/m2) and Carboplatin (AUC-5). Out of the 31 patients diagnosed with ATC, clinicopathological profile of 29 patients was analyzed (2 patients who underwent upfront surgical resection with curative intent were excluded), out of which 20 patients were included in the survival analysis. The median age of presentation was 55.8 years with male:female ratio 1.9:1. Seventeen out of the total 29 patients presented with anaplastic transformation in long-standing goiter. Nineteen out of 20 (95%) patients presented with distant metastasis with lungs being the most common site. Nodal metastasis was present in all patients. Invasion of the strap muscles (90%) and trachea (80%) was the most common peri-thyroidal tissue invasion followed by invasion of the esophagus (40%), internal jugular vein (30%), and carotid artery (5%). Twelve out of the 20 patients opted for palliative chemotherapy. Overall, median survival from the time of diagnosis was 2.6 months, with median survival in patients receiving chemotherapy 3.1 months and those opting for supportive care 1.6 months (p=0.004). Out of all the factors analyzed, male sex (HR 6.521, 95% CI 1.143-37.206, p value 0.03) and vascular invasion (HR 0.066, 95% CI 0.009-0.499, p value 0.008) were poor prognostic indicators. Palliative chemotherapy showed increased survival benefit in patients with metastatic ATC. Male sex and vascular invasion were found to be significant factors associated with poor outcomes on Cox regression analysis.

Prevalence and Psychobiological Correlates of Depression Among Breast Cancer Patients.

The diagnosis of breast cancer (BC) is associated with psychological stress. Various factors that contribute to psychological reactions are from the diagnosis of cancer to long uncertain treatment. A patient develops many fears in their mind starting after the diagnosis of cancer. Fear of cancer being an incurable disease, changes in body image, fear of death, separation from loved ones, and fear of pain all contribute to psychological disorders and most common disorders in cancer patients are mood, anxiety, depression, and sexual functional disorders. Research studies focus more on cancer. Only a few studies emphasized the coexistence of stress, depression, and the abilities of the individual to cope with such stressors. Depression is a comorbid illness to cancer, and if neglected, it may complicate the treatment of both illnesses, which will result in poor adherence to treatment and less desirable outcome of both the illnesses. Studies from this perspective can have meaningful implications, and can address both areas. Every clinician involved in the care of BC should also plan assessment of stress and depression and arrange medical treatment or coping interventions if symptoms are present. This review article aims to find the prevalence and psychobiological correlates of depressive disorder and its effect on mortality in women diagnosed with BC.

Impact of cytological pitfalls in the Bethesda System of Reporting Thyroid Cytopathology, on surgical decision-making of patients with thyroid nodules: Can these pitfalls be avoided?

INTRODUCTION: The purpose was to assess diagnostic accuracy of the Bethesda System of Reporting Thyroid Cytopathology, reasons for disagreement and cytological pitfalls with impact on surgical decisions in patients with thyroid nodules. METHODS: Cases of thyroid cytology with histological follow up were included followed by cytological-histological correlation and were reviewed to look for reasons for discrepancies. The impact of disagreements and partial agreements on surgical decision was evaluated. Overall and complete diagnostic accuracy were calculated along with sensitivity, specificity, and positive and negative predictive values for malignant and neoplastic lesions. RESULTS: Of 446 cases included in the study, there was complete agreement in 358 cases, partial agreement in 22 cases and disagreement in 66 patients. Overall diagnostic accuracy was 98.5% with sensitivity, specificity, positive predictive value and negative predictive value of 80%, 99.6%, 100%, 72.7% and 94.3% respectively for malignant lesions. Overall diagnostic accuracy was highest for the malignant category. Follicular patterned lesions, Hürthle cell-rich smears and overlapping cytological features between benign and malignant follicular neoplasm were the main reason of discrepancy. The discrepancy in cytological diagnosis altered the decision of type of surgery performed in 13.6% of the patients. CONCLUSION: Fine needle aspiration cytology remains a powerful screening tool to aid decision-making in the majority of the patients. Histological-cytological discrepancy can adversely impact the management of patients. Factors causing an adverse impact on surgical management were rare and potential avoidable reasons for them were identified. Cytological pitfalls may be avoided through screening for minor components, clinico-radiological correlation and experience.

Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges.

Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intra-operative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2-60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: [Table: see text] There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes.

Barriers to Timely Diagnosis and Management of Breast Cancer: Observations from a Tertiary Referral Center in Resource Poor Setting.

Breast cancer (BC) is the most common cancer among females worldwide, with over 2 million cases diagnosed every year. In India, it is the most common malignancy overall (15.4%) and accounts for about 27% female cancers. Morbidity and mortality remain high despite improvements in BC therapeutics. Conventionally, a gap of more than 3 months between noticing symptoms and commencing treatment is considered delay in BC management. Delays make BC an important public health problem and lead to poor outcomes. This study aims to identify patient perceived barriers to BC management. A self-designed structured questionnaire consisting of questions pertaining to multiple aspects of BC presentation and management was prepared. The study was conducted from October 2017 to September 2018 and results were analyzed. A delay of 3 months or more was seen in 284 of the 435 patients (65.3%), among which 179 was patient delay, 69 due to provider delay, and 36 due to a combined contribution of both factors. Provider factors were associated with prolonged delay. Misdiagnosis at first consult was the most common factor perceived by patients as a barrier, followed by delay in referral, distance from hospitals, lack of information, financial constraints, and logistic issues. A significant patient and provider delay exists in BC management which prevents effective early therapy. Effective tackling of these barriers may result in the betterment of BC management outcomes. Robust screening, education of patients and providers, and awareness promotion and infrastructure development will be useful in this regard.

P-Glycoprotein Expression in Indian Breast Cancer Patients with Reference to Molecular Subtypes and Response to Anthracycline-Based Chemotherapy-a Prospective Clinical Study from a Developing Country.

Chemo-resistance is an important factor determining the response of tumor to neoadjuvant chemotherapy (NACT). Our study was aimed to determine the role of P-glycoprotein (P-glyp) expression as a predictor of response to NACT in locally advanced breast cancer (LABC) patients with special reference to molecular subtypes. Sixty cases of locally advanced breast cancer (LABC) were subjected to trucut biopsy and the tissue samples were evaluated immunohistochemically for P-glyp, ER, PR, and Her 2 neu status. Pre- and post-NACT P-glyp expression was correlated with clinical response (using WHO criteria after three cycles of CEF regimen) and molecular subtypes. The change in the P-glyp expression before (pre-) and after (post-) NACT was statistically significant with higher stage (p = 0.02), hormonal negative molecular subtypes (p = 0.01), and poor clinical response (p = 0.01). Pre-NACT-positive P-glyp expression is associated with higher stage and hormonal negative molecular subtypes and poor clinical response. The increased expression of P-glyp induced by NACT likely explains the concept of acquired chemo-resistance and may prove as an intermediate checkpoint in determining chemo-sensitivity for further treatment so that additional doses of ineffective chemotherapy may be avoided in non-responders translating into better patient safety.

A Survey on Breast Cancer Awareness Among Medical, Paramedical, and General Population in North India Using Self-Designed Questionnaire: a Prospective Study.

Breast cancer (BC) has become the most common cancer in urban women. Unfortunately, most women are not aware of BC symptoms/signs, prevention, and management. In resource-limited countries like India where we do not have structured screening/awareness programs, a majority of women present with locally advanced BC. The aim of our study is to identify the present status of awareness about BC prevention, early detection, symptoms, and management in urban and rural Indian women (medical, paramedical, and nonmedical) and to assess whether education and socioeconomic strata have any role in better awareness about BC or not. We did a prospective cross-sectional observation study among the medical, paramedical, and nonmedical women in the northern part of India. We designed a questionnaire keeping in mind the three domains about BC-knowledge (questions 1-25 include risk factors, genetics, lifestyle changes, hormones, associated cancers, and modes of presentation like lump, nipple/skin changes), breast self-examination (questions 25-37), and attitude to prevention and early detection (questions 38-44). We also asked how many do breast self-examination (BSE) and what they think are the three main factors responsible for late presentation and the three main ways to increase BC awareness. The Likert scale was used for objective assessment. We analyzed the whole data using SPSS software version 15. A total of 220 women out of 270 completed the questionnaire. Out of 220 women, 26.4% were medical, 20.9% paramedical, and 52.7% nonmedical. Most women were educated (82.7%) and married (65%). 59.5% women resided in urban areas and the rest (40.5%) were from rural areas. We found that there was relatively more knowledge in the medical group; however, the skills of BSE and attitude to prevention and early detection in all the three subgroups and among rural and urban women were suboptimal and not different significantly. The three main factors responsible for delayed presentation were shyness and not knowing BSE, ignorance about BC symptoms, and social stigma of cancer along with financial constraints. The three main ways to improve BC awareness suggested were to have more advertisements on television and social media, roadside campaigns and in colleges along with group discussions and debates, and at grassroots level to involve Anganwadi workers and nurses to create more awareness in villages. There was less breast cancer knowledge and awareness among the nonmedical women compared to those among the medical and paramedical, the skills of BSE and attitude to prevention and early detection were suboptimal in all the three groups. Rural or urban dwellings did not make much difference in BC knowledge, skills of BSE, and attitude to prevention. More awareness regarding breast cancer symptoms with early detection and BSE need to be addressed with more information dissemination via social media, campaigns, and involvement of paramedics and social workers.

Expression of vitamin D receptor and vitamin D status in patients with oral neoplasms and effect of vitamin D supplementation on quality of life in advanced cancer treatment.

AIM OF THE STUDY: Vitamin D receptor (VDR) expression and serum vitamin D scores in oral premalignant lesions and oral cancer have not been widely analyzed. The role of vitamin D supplementation in advanced oral cancer for improving quality of life (QOL) is also a matter of research. MATERIAL AND METHODS: Vitamin D receptor expression and vitamin D scores were analyzed in normal oral mucosa (n = 95), leukoplakia (n = 23) and oral cancer (n = 87). 45 patients with advanced oral cancer subjected to chemoradiation were evaluated for the effect of vitamin D supplementation on most observable QOL parameters such as oral mucositis, swallowing performance and overall QOL. RESULTS: Vitamin D receptor expression was increased in oral neoplastic lesions. Vitamin D scores were significantly lower in cases compared to healthy controls (p = 0.002). Vitamin D supplementation significantly reduced the therapy-related toxicities in advanced cancer, thus reducing morbidity and improving QOL. CONCLUSIONS: Vitamin D receptor expression is increased in premalignant lesions and oral cancer. Vitamin D insufficiency and deficiency are prevalent in patients with oral neoplastic lesions. Vitamin D supplementation has a role in reducing treatment-related toxicities, especially in advanced cancer.

Left-sided transmesocolic herniation of small bowel in an otherwise unaffected abdomen.

Transmesocolic hernia is an uncommon type of internal hernia with incidence ranging from approximately 5-10%. To the best of our knowledge, this is the first reported case of a transmesocolic hernia through a gap within the descending mesocolon presenting clinically as an intestinal obstruction. A 75-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency surgery was performed. Strangulated bowel loops with gangrenous changes were resected and double-barrel ileostomy was carried out. The postoperative period was uneventful. Restoration of bowel was performed after 6 weeks. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as peritonitis and sepsis.