BRCA1 promoter methylation & its immunohistochemical correlation in sporadic breast cancer.

Background & objectives: Studies have shown that apart from hereditary breast carcinomas, breast cancer susceptibility gene 1 (BRCA1) mutations conferring to its loss are seen in sporadic breast carcinomas (SBC) as well. The aim of the present study was to assess BRCA1 methylation in females presenting at King George's Medical University, Lucknow, with SBC by both immunohistochemistry (IHC) and methylation PCR with respect to hormonal profile and various morphological prognostic parameters. The primary objective was to look for the association between BRCA1 protein expression and DNA promoter methylation. Methods: 81 mastectomy specimens from SBC of invasive breast carcinoma (no special type) were included in this study. After a detailed morphological assessment, formalin fixed paraffin embedded tissue from a representative tumour area was selected for BRCA1 IHC by heat-mediated antigen retrieval under high pH and DNA extraction and further bisulphate treatment. BRCA1 was studied for methylation by methylated and unmethylated PCR-specific primers. Results: BRCA1 promoter methylation was present in 42/81 (51.9%) participants, with significant BRCA1 protein loss (72.7%; P=0.002). A significant association between BRCA1 loss and hormonal profile was found (P=0.001); maximum in triple negative breast carcinoma (TNBC) (72%; 18/25). Most of the TNBC also harboured methylation (68%). Although not significant grade II and III tumours, lymph vascular invasion, ductal carcinoma in situ, and nodal metastasis (≥3) were seen in a higher percentage in methylated tumours. Mortality in SBC was significantly associated with BRCA1 loss (30.3%; P=0.024). Interpretation & conclusions: Study results highlight the concept of "BRCAness" in SBC as well. Hence, we can confer that identification of BRCA1 loss in SBC can make it a perfect candidate for poly ADP-ribose polymerase inhibitors or cisplatin-based therapy like hereditary ones.

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.

Guided Needle Aspirations of Intra-Abdominal Masses: Analogy between Liquid-Based and Conventional Smear Preparation Methods.

OBJECTIVE: Image-guided fine needle aspiration cytology with conventional smear (CS) preparation offers onsite cellular adequacy evaluation; however, it still provides false negatives due to faulty smear preparations. Liquid-based cytology (LBC) can be advantageous in these scenarios. Hence, with an aim to investigate utility of LBC in these samples, we carried out the above study with objectives to find diagnostic accuracy of LBC and agreement of LBC with CS methods in guided aspiration samples from intra-abdominal masses. METHODS: A prospective observational study, of 113 patients with clinical or radiological diagnosis of intra-abdominal masses, was carried out. SurePath BD™ was used for LBC smear preparation, and the standard protocol was used for CS preparation. RESULTS: LBC alone was diagnostic in 80.8% of the cases, and CS alone was diagnostic in 71.2% cases (agreement was 83.7%, p = 0.03). Cellular morphology was better preserved in LBC; however, interpretation was easier in CS. CONCLUSION: CS may be complimented with LBC sample collection method to enhance the sensitivity of intra-abdominal FNA.

Co-Relation of Hormonal Profile and BRCA1 in Sporadic Breast Carcinoma: A Single Institutional Experience of 303 Patients.

INTRODUCTION: Invasive Breast carcinoma-No special type (NST) is the most common breast malignancy accounting for 95% of breast cancers. Study of predictive and prognostic immunohistochemical markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her2neu) expression are crucial for treatment planning. MATERIALS AND METHODS: In the present study we studied the hormonal profile in 303 sporadic breast cancers and BRCA1 protein expression in these patients along with its clinico-pathological correlation. RESULTS: In our patient population, Triple negative Breast carcinoma (TNBC) (104/303; 34.3%) was the most common luminal subtype followed by Luminal A 74/303; 24.4%), Her2 enriched (65/303; 21.5%), and Luminal B (60/303; 19.8%) respectively. This contrasts with many western studies which commonly report Luminal A being the largest subgroup. BRCA1 protein loss was more prominently seen in TNBC (64/104;61.5%) highlighting the possibility that high grade tumors are more susceptible to some epigenetic modifications leading to higher likelihood of loss of BRCA1 protein. CONCLUSION: Hence, we conclude that like hereditary cases of breast carcinoma with BRCA1 mutation; BRCA1 loss is also more likely in sporadic TNBC cases.

Comparison of circulating DNA in malignant neoplasia from diverse locations: Investigating a diagnostic role.

CONTEXT: Circulating free DNA (cfDNA) analysis has emerged as novel noninvasive diagnostic biomarker in several solid tumors. Raised levels have been reported in several malignancies and may correlate with clinicopathological and treatment response. The current study was designed to assess the diagnostics of cfDNA in different tumor types of malignancies correlating with tumor (T), nodes (N), and metastases (M) stage. DESIGN: Serum samples were collected from treatment naïve cases with histologically diagnosed tumors including 23 brain tumors, 48 breasts, 50 gallbladder carcinoma (GBC), 13 lungs, 68 oral squamous cell carcinoma (OSCC), and 25 normal controls. CfDNA was quantified with real-time polymerase chain reaction (PCR), Invasive ductal carcinoma (IDC) using beta-globin gene amplification. Cut off values for diagnostics were calculated using receiver operating curve analysis. RESULTS: Contrary to other cfDNA studies where it was postulated that cfDNA would not cross the blood-brain barrier and reach the systemic circulation, we found detectable cfDNA in glioma with median (Q1-Q3) of 349.22 ng/ml (19.87-1276.58). Median cfDNA concentration in breast, gallbladder, lung, oral and normal controls was 328.72 (128.38-624.44), 778.50 (589.88-1864.35), 348.73 (194.67-483.61), 386.27 (47.88-959.67), and 74.12 (49.66-120.00), respectively. Grades I and II glioma had significantly lower levels compared to Grades III and IV (P = 0.0001). Significant difference in median cfDNA values in IDC and GBC was observed with increasing tumor grades, stage, T stage, nodal stage and metastasis and with stage of OSCC cases. CONCLUSION: CfDNA levels showed good diagnostic discrimination in glioma, GBC, breast, lung carcinoma, and OSCC. Significant increase in titers was evident with increase in cancer stage from I to IV in breast, GBC and OSCC.

Nodular Hidradenocarcinoma, Trichelemmal Carcinoma and Squamous Cell Carcinoma with Clear Cell Changes: Pitfalls of Biopsy Diagnosis of Skin and Adnexal Tumours.

Skin and Adnexal tumours are a group of benign and malignant tumours whose basic diagnosis relies on histopathology. A single tumour may show more than 1 appendageal differentiation. Morphologic distinction between benign and its malignant counterpart is of utmost importance as it affects the treatment and prognosis of patient. We have described 3 cases who presented in our university hospital, in which final resection pathological diagnosis differed from initial core biopsy interpretation. The authors have made an attempt to provide a brief overview of diagnostic overlap existing between nodular hidradenocarcinoma and tumours of clear cell histology. Salient morphologic features differentiating cylindroma or trichilemmal carcinoma from squamous cell carcinoma have also been discussed. Final diagnosis is paramount for adjuvant management and prognostication of the patient in a clinical setting.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Transfascial suture versus tack fixation of mesh in totally extraperitoneal repair of inguinal hernia: A prospective comparative study.

Purpose: Among laparoscopic surgeries in inguinal hernias, totally extraperitoneal (TEP) repair has demonstrated favourable results in reduction of post-operative pain and mean operative times with early return to physical activity. We have done a prospective comparative study on two different techniques of mesh fixation, i.e., transfascial suture and tack fixation. Materials and Methods: It was a prospective, non-randomised comparative study done on inguinal hernia patients operated by TEP repair from October 2014 to September 2016. These data were compared in two techniques of mesh fixation (tack and transfascial sutures) in terms of post-operative complications, pain scores by visual analogue scale (VAS) and cost analysis of the procedure. Results: Our study on 69 total patients (44 tack fixation and 25 suture fixation group) revealed that mean VAS scores for post-operative pain were not having any statistically significant difference in the tack group versus suture group (2.42 ± 0.24 vs. 2.2 ± 0.24) at 24 h, but VAS scores in the follow-up period at 1 week, 1 month, 3 months and 6 months were 1.14 ± 0.33 versus 0.67 ± 0.27; 0.78 ± 0.24 versus 0.07 ± 0.06; 0.42 ± 0.17 versus 0.07 ± 0.06 and 0.5 ± 0.11 versus 0.07 ± 0.06, respectively, which showed significant difference at 1 and 3 months, suggesting less pain in the suture group. No significant difference was noted in other post-operative complications. Conclusion: Transfascial suture fixation of mesh in TEP repair of inguinal hernia can be a cost-effective procedure with a comparable safety profile as compared to tack fixation.

Vitamin D Receptor and Role of Vitamin D Supplementation in Advanced Gallbladder Cancer: A Prospective Study from Northern India.

BACKGROUND: The proposed role of Vitamin D Receptor (VDR) in various cancers underscores the importance of vitamin D compounds as a novel therapeutic agent in the prevention of occurrence and progression of cancer. Vitamin D Receptor (VDR) expression in gallbladder cancer (GBC) has not been widely analyzed yet. In the present study, an attempt has been made to study VDR expression and the role of vitamin D supplementation during palliative chemotherapy in advanced GBC. METHODS: Expression of VDR was analyzed in benign cholecystectomy specimens (n=11), and GBC specimens (n=32). Thirty patients with advanced GBC were subjected to palliative chemotherapy. Out of them, 19 patients were supplemented with Vitamin D and 11 patients were not. Effect of vitamin D supplementation on the change in vitamin D scores and improvement in quality of life (QOL) were assessed by EORTC QLQ c30 version 3.0. and the difference in outcome between the two groups were studied. RESULTS: Mean intensity, staining and immunoreactivity scores signifying VDR expression were decreased in the studied population of GBC when compared to benign disease. In palliative setting, vitamin D supplementation significantly improved the quality of life. However, the effect on disease- specific survival, although present, was not statistically significant. CONCLUSION: VDR expression downregulation is associated with increasing malignant process. Vitamin D may act as sensitizers for tumor cell death besides downplaying potential harmful effects of palliative chemotherapy thus reducing the associated morbidity. This study assumes importance as the first clinical study reporting VDR expression in GBC tissue and the possible role of vitamin D supplementation in patients with advanced disease.

Diagnostic Value of Circulating Free DNA Integrity and Global Methylation Status in Gall Bladder Carcinoma.

The current study investigates the role of circulating free DNA (cfDNA) as a liquid biopsy in diagnosis gall bladder carcinoma (GBC) utilizing levels of long DNA fragments (ALU247) derived from tumor necrosis, short apoptotic fragments (ALU115) denoting total cfDNA and cfDNA integrity denoting ratio of ALU247 and ALU115. The global methylation status of cfDNA was also estimated with the hypothesis that these parameters provide a diagnostic distinction between cancer and non-cancer subjects, with higher or altered values favoring presence of malignancy. Study group included 60 cases of GBC and 36 controls including diseased controls (cholecystitis) and healthy subjects. Median levels of ALU115, ALU247 and cfDNA integrity were significantly different in GBC at 1790.88, 673.75, 0.4718 vs. controls at 840.73, 165.03, 0.1989 ng/ml respectively. Global DNA methylation was not significantly different between GBC at 0.679% and controls at 0.695%. The sensitivity and specificity of ALU 247 in discriminating GBC from controls was highest with a sensitivity, specificity and diagnostic accuracy of 80.0%, 86.1% and 82.2% respectively. Global DNA methylation showed lowest sensitivity of 55.0% and specificity of 50.0%. Clinico-pathological parameters showing significant association with cfDNA integrity, on ROC curve analysis, showed significant diagnostic discrimination of the tumor stage, lymphovascular invasion, disease stage and grade histology. This is a first time analysis of ALU115, ALU247 and cfDNA integrity in the diagnosis of GBC and confirms that the combination of ALU247 and cfDNA integrity provides good sensitivity, specificity and diagnostic accuracy in discriminating GBC from controls as well correlates with aggressive disease parameters.

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.

Safety and Efficacy of Low-Dose Single-Agent Capecitabine in Inoperable Gallbladder Cancer with Jaundice Post-Single-System Single-Catheter External Biliary Drainage: a Pilot Study from a Highly Endemic Area.

Gallbladder cancer (CaGB) in the subcontinent belongs to low socioeconomic status, and at the time of diagnosis, a large number is unresectable or inoperable so the palliative treatment remains the only option. In the present study, attempt was made to see the effect and safety profile of single-agent oral capecitabine in inoperable CaGB in presence of low levels of jaundice post-single-catheter transhepatic external biliary drainage. In N = 35 of inoperable jaundiced CaGB, post-biliary drainage capecitabine in low dose was started when their total bilirubin levels fell to 10 mg% or below. Post-external drainage decreased bilirubin level to < 10 mg/dl within 1-4 weeks, mean 2.37 ± 0.80 weeks. Survival was 1-6 months, mean 3.26 ± 1.46 months. Catheter patency time was 1.92 ± 0.64 months (range 0-3 months). Young age, male sex, level of jaundice at presentation, and duration of decrease in jaundice after drainage were significantly associated with progressive disease course. Poor survival was significantly associated with progressive disease course, young age, and level of jaundice at admission. To the best of our knowledge, this is the first study to establish that single-agent capecitabine can be safely given in CaGB in presence of jaundice.

A Prospective Nonrandomized Study of Comparison of Perioperative and Quality of Life Outcomes of Endoscopic Versus Open Inguinal Hernia Repair: Data from a Developing Country.

OBJECTIVES: To determine the perioperative outcomes and quality of life (QOL) following endoscopic inguinal hernia repair (EIH) versus open inguinal hernia repair (OIH) using the hernia-specific Carolinas Comfort Scale® (CCS) questionnaire. MATERIALS AND METHODS: A prospective nonrandomized study from September 2014 to August 2015 included all patients who underwent elective primary endoscopic (totally extraperitoneal repair/transabdominal preperitoneal) or OIH. Baseline patient characteristics were recorded in addition to mean operating time, intraoperative and postoperative complications, return to work, and QOL. RESULTS: Mean operative duration was significantly longer in EIH compared with OIH (102.5 ± 11.9 minutes versus 66.9 ± 12.7 minutes, P = .001). Mean duration of hospital stay (5.7 ± 1.3 days versus 2.6 ± 0.6 days, P = .001), time to return to routine work (5.8 ± 1.1 days versus 3.7 ± 0.8 days, P = .001), and return to office work (OIH versus EIH: 12.3 ± 1.9 days versus 7.6 ± 0.8 days, P = .001) were significantly shorter in EIH. Intraoperative and postoperative complications were comparable in both the groups, except for surgical site infection, which was more with OIH (20.3% versus 5.6%, P = .04), and postoperative pain scores, which were reduced in EIH. QOL was better in EIH with a significant decrease in terms of sensation of mesh, postoperative pain, and movement limitation. CONCLUSIONS: Endoscopic hernia repair offers reduced hospital stay, equivocal perioperative complications, reduced postoperative pain, and early return to normal activity and work. This assumes importance in developing countries as most of the patients are the sole earning member in the family. QOL is also significantly improved with endoscopic repair with a considerable change for better with time.

Human Papilloma Virus in Oral Cavity Cancer and Relation to Change in Quality of Life Following Treatment-a Pilot Study from Northern India.

Human papilloma virus (HPV)-associated head and neck cancer (HNC) has generated significant amount of research interest in recent times with focus shifted to oral cavity squamous cell cancer (OCSCC) after oropharyngeal cancer. Due to high incidence of OCSCC and anecdotal reports on association of HPV infection from northern region of India, this study was conceived to investigate HPV infection and establish its association with lifestyle habits such as tobacco, alcohol consumption, oro-genital sex, number of sexual contacts, and change in quality of life posttreatment. A total of 43 primary OCSCC biopsy specimens were collected. These samples were analyzed for HPV DNA genotyping which was done by using 13 high-risk HPV real-time PCR kits. Quality of life was assessed using University of Washington questionnaire for HNC patients, which was administered pretreatment and 3-months posttreatment. HPV presence was confirmed in only three patients (7.0 %). HPV positivity did not find any statistical correlation with age, gender, residence, addiction habit, stage, tumor size, nodal status, tumor grade, and number of sexual contacts. There was no significant (p > 0.05) difference in the average percent change in QOL parameters from pretreatment to posttreatment when correlated with HPV status.

Morel-Lavallee seroma (post-traumatic pseudocyst) of back: a rarity with management conundrum.

Morel-Lavallee seroma (MLS) or post-traumatic pseudocyst is a soft tissue seroma developing due to closed degloving injury by a shearing force that causes separation of subcutaneous fatty layer from the deeper muscular fascia resulting in collection of fluid in the created space. Presentation is usually fluctuant swelling following history of injury. More frequently described in orthopaedic literature, it occurs more commonly over gluteal and trochanteric regions, knee and flanks with occurrence over back, thorax being a rare entity. Despite mimicking several other similar presenting conditions, diagnosis of MLS can be made by meticulous history and physical examination with classical findings on ultrasonography, CT scan and MRI. Treatment modality may vary from conservative management to open surgical debridement of the wound with percutaneous aspiration and sclerodhesis forming useful adjuncts to conservative management.