Neuromucormycosis of Posterior Tibial Nerve: A Rare Presentation of Mucormycosis.

Opportunistic fungal infections are known to occur in immunocompromised patients. Mucormycosis is one of the most common opportunistic fungal infections with significant mortality rates. In this article, we present a case of an adult female, a known diabetic who presented with fever and pus discharge from the amputation site of toes in the left foot with blackening of the foot. Examination revealed gangrenous changes of the left foot with no distal pulses palpable. Computed tomography angiogram revealed no flow of blood in distal vessels of the left lower limb. Left below knee guillotine amputation was done. Intraoperative biopsy of the neurovascular bundle revealed invasive neuromucormycosis. She was started on liposomal amphotericin B. The wound started granulating after a few days with serial dressings and the patient was planned for split skin grafting.

Modified neoadjuvant clinicopathological risk stratification as a prognostic score in early and locally advanced triple-negative breast cancer.

Background: Triple-negative subtype is an aggressive breast cancer with inferior survival. Pathological complete remission (pCR) is a good surrogate endpoint for survival among patients receiving neoadjuvant chemotherapy (NACT). We attempted to validate the clinical pathological score (CPS) with a modified risk grouping among Triple-negative breast cancer (TNBC) patients receiving NACT at our center. Methodology: Data of patients with TNBC who underwent NACT between January 2014 to July 2017 were retrospectively analyzed. The composite CPS score included cTN stage and y pTN stage and ranged from 0 to 4. This was calculated using an available online software developed by MD Anderson Center. The score obtained from the calculator was used to develop a risk grouping into low risk (0, 1) and high risk (2, 3, 4). Invasive disease-free survival (iDFS) and locoregional recurrence-free survival (LRFS) were calculated using the Kaplan-Meier method. Results: Seventy-eight patients with TNBC (median age: 45 [24-75]) had received NACT (anthracyclines and taxanes). Early and locally advanced breast cancer constituted 17 (21.8%) and 61 (78.2%), respectively, and 22 (28.2%) achieved pCR. After a median follow-up of 25 months (5-62), 3-year iDFS and OS were 59% and 81%, respectively, for the entire population. The 3-year iDFS in low-risk (n = 18) and high-risk (n = 60) patients was 85% and 51%, respectively (P = 0.03). The 3-year LRFS in low risk and high risk was 93% versus 58% (P = 0.03). The 3-year OS in the low and high risk was 93% and 77%, respectively (P = 0.24, NS). Conclusion: Our study supports the use of the modified neoadjuvant clinicopathological score as a prognostic marker in patients with nonmetastatic triple-negative breast cancer. This needs to be validated in a larger subset of patients.

Evaluation of change in tumor stiffness measured by acoustic radiation force impulse imaging for early prediction of response to neoadjuvant chemotherapy in breast cancer.

OBJECTIVES: In this study, the role of change in tumor stiffness between pre- and post-two cycles of neoadjuvant chemotherapy (NACT) measured by Acoustic Radiation Force Impulse (ARFI) imaging for predicting the response to NACT in breast cancer was analyzed. METHODS: Fifty-two adult women with biopsy-proven locally advanced breast cancer and early-stage breast cancer who received NACT followed by either modified radical mastectomy or breast conservation surgery were included in the study. Tumor stiffness represented by shear wave velocity (SWV) in meter per second by ARFI imaging was measured before and after two cycles of NACT. Participants were categorized into responders and nonresponders based on pathological response assessment from the postoperative specimen. The association of change in tumor stiffness between pre- and post-two cycles of NACT with final pathological response status was assessed. RESULTS: The mean change in SWV before and after completion of two cycles of NACT was 0.42 ± 0.16 and 0.17 ± 0.11 m/s in responders and nonresponders, respectively, and this difference was proven to be statistically significant (p < 0.001) suggesting that tumors that exhibit a larger reduction in tumor stiffness, respond better. An SWV reduction cut-off of 0.295 m/s between baseline and post-two cycles of NACT was also arrived at, which can discriminate between responders and nonresponders with a sensitivity and specificity of 88% and 83%, respectively. CONCLUSION: Difference in tumor stiffness measured by ARFI imaging before and after two cycles of chemotherapy can be used as a reliable early predictor of response to chemotherapy in breast cancer.

Dosimetric comparison between interstitial brachytherapy and volumetric-modulated arc therapy for tumor bed boost in breast cancer.

PURPOSE: To dosimetrically compare high-dose-rate interstitial brachytherapy (HDR-BT) with volumetric-modulated arc therapy (VMAT) for tumor bed boost, following breast conservative treatment. MATERIAL AND METHODS: 50 patients with early-stage breast cancer who underwent breast conservation surgery, followed by either HDR-BT (n = 25) of 15 Gy in 6 fractions over a period of 3 days, or VMAT dose of 16 Gy in 8 fractions (n = 25) for tumor bed boost, were retrospectively reviewed. All patients received whole breast irradiation of 46 Gy in 23 fractions. Dosimetric parameters for organs at risk (OARs), including ipsilateral and contralateral lungs, heart, contralateral breast, skin, and ribs, were evaluated with the help of dose-volume histograms (DVH). RESULTS: Heart sparing was similar in both modalities (left-sided breast irradiation, HDR-BT D2cc 20.5% vs. VMAT 30.2%, p-value = 0.243; right-sided breast irradiation, D2cc 6.5% vs. 4.4%, p-value = 0.165). Left-sided cases received higher dose to heart compared to right-sided patients. Interstitial brachytherapy resulted in significantly less dose to contralateral breast (D2cc 4.3% vs. 9.6%, p-value < 0.0001), ipsilateral lung (D2cc 27.6% vs. 73.2%, p-value < 0.0001), contralateral lung (D2cc 4.2% vs. 14.5%, p-value < 0.0001), ribs (D2cc 24.1% vs. 41.2%, p-value < 0.0001), and skin (D2cc 77.3% vs. 95%, p-value < 0.0001). CONCLUSIONS: HDR-BT-based tumor bed boost irradiation results in significantly lower doses to most organs at risk with similar heart sparing compared to VMAT.

Malignant phyllodes tumor with liposarcomatous differentiation: Diagnosed on cytology.

Phyllodes tumor (PT) accounts for less than 1% of all primary tumors of the breast and 2% to 3% of all fibroepithelial lesions. We report a case of heterologous liposarcomatous elements in a malignant PT of the breast on Fine needle aspiration cytology (FNAC) and later confirmed by histopathological examination. A 58-years-old woman presented with a huge breast mass for which FNAC was done. Cytology showed features of malignant PT with a good representation of heterologous liposarcomatous areas. The cytological findings were in concordance with the histologic features. Malignant PT and its various heterologous elements of stroma can be diagnosed on FNA cytology when performed optimally. They can be vital for the preoperative assessment of patients suspected with malignancy to formulate the surgical plan accordingly.

Lateral Thoracodorsal Flap Revisited: An Underappreciated Workhorse.

BACKGROUND: Although, the lateral thoracodorsal flap is a well described technique, its utility seems to be lost in the ever evolving world of oncoplastic breast surgery. This study reviews the technique, its indications and limitations and the advantage of this technique. METHODS: Between January 2016 and January 2018, data from 7 consecutive patients who underwent partial breast mastectomy with lateral thoracodorsal flap were enrolled. A wedge shaped flap was designed using the pinch test using the index finger and the thumb in small defects, while larger defects required a convex shaped incision with curved superior and inferior borders. Incision was made along the marked margins of the proposed flap and deepened to the underlying serratus anterior and latissimus dorsii muscle. The flap was transposed in the defect and the symmetry of mound between the two breasts confirmed in sitting and supine position. RESULTS: All patients were satisfied by cosmetic outcomes on visual analog scale (VAS). Cosmetic results based on Harvard scale showed good to excellent scores. Evaluation by Breast Cancer Conservation Treatment (BCCT) core software illustrated good to excellent cosmetic outcomes. There was no delayed wound healing, marginal skin ornecrosis and no evidence of any fat necrosis in the follow up period. CONCLUSION: The versatility of latissimus dorsii flap, good aesthetic and functional results and its simple execution made it an important option in the armamentarium of the oncoplastic breast surgeon. Also, morbidity of the donor site was minimized without sacrificing muscles or nerves.

Medullary carcinoma of thyroid metastasis to breast: A cytological experience.

Medullary carcinoma of thyroid is a relatively uncommon malignancy, which can be sporadic and syndromic in nature. It commonly spreads to regional lymph nodes followed by spreading to distant sites. Breast is an uncommon site of metastasis of this malignancy. Our case is a 38-year-old woman married parous woman presenting to the outpatient department with complaints of lump in both the breasts. Fine-needle aspiration (FNA) was attempted, which revealed a malignancy more suggestive of a metastasis, which was confirmed on CT scan. A detailed history revealed that the patient is a known case of medullary carcinoma of thyroid. The report was given as metastatic medullary carcinoma to the breast after confirming with a calcitonin immunostain. Given the versatility of primary lesions in the breast, minimally invasive FNA cytology (FNAC) technique with adequate sampling helps in identifying metastatic lesions. Differentiating primary from metastatic lesions changes the course of management to the patient. Metastatic lesions should always be kept in mind in the occurrence of known malignancies, however rare the site of occurrence may be. Morphological clues and immunohistochemical work up aid in arriving at correct diagnosis.

Oral versus topical tamoxifen in cyclical mastalgia-A randomized controlled trial.

Mastalgia affects premenopausal in which cyclical mastalgia affects up to 40% of women. In approximately 8% of these women, pain will be severe and interfere with their normal activities. oral tamoxifen widely used in the treatment of mastalgia is associated with a wide range of side effects. Topical tamoxifen has the potential to be a more efficacious and safer alternative with lower blood drug levels hence having lower systemic side effects. To compare reduction in the pain, nodularity and blood drug levels of tamoxifen using topical verus oral tamoxifen in cyclical mastalgia. Patients who presented to the surgery outpatient department with complaints of breast pain were provided with a breast pain evaluation questionnaire. Patients were randomized using a computer generated sequence into two groups with 75 participants in each group. In Group 1, the participants received topical tamoxifen gel and a placebo tablet for 3 months, and in Group 2, the participants received Oral Tab Tamoxifen 10 mg OD and a placebo gel for 3 months. They were provided with a Cardiff Breast Pain assessment chart and asked to mark the severity of their pain and response to treatment in the following month and asked to report to the investigator. Patients were called for review every month, and the pain chart was monitored and documented. The response to therapy (relief of pain) was assessed after 3 months of treatment and once more at the end of 6 months for recurrence. After completion of 1 month of treatment, blood sample was drawn to check for the blood drug levels. There is a significant difference of mean pain score between oral and topical tamoxifen groups (P < .001) at the end of 1 month, 3 months (P < .001), and 6 months (P < .001). There is a significant difference in the Nodularity found between oral and topical groups at presentation (P = .004), at 1 month (P = .003) and at 6 months (P < .001). There is a significant difference of mean blood tamoxifen level (ng/mL) in oral and topical tamoxifen groups (P < .001). From this study, we conclude that topical tamoxifen is more effective than oral tamoxifen treatment in reducing cyclical breast pain and decreasing breast nodularity with lesser side effects and lower recurrence rates.

Uncommon complication of feeding jejunostomy: A case report.

Feeding jejunostomy is a common surgical procedure performed for patients who cannot take oral feeds. Although a minor procedure, it is not without complications. However, distal migration of the tube into the bowel is extremely rare. A 50-year-old woman with corrosive stricture of the esophagus because of feeding jejunostomy feeds presented with internal dislodgement of the feeding tube. Abdominal X-ray and ultrasonogram could not locate the tube. On computed tomography, the feeding tube was found in the descending colon. She was managed conservatively, and the tube was expelled after three days. Internal dislodgement of tube usually does not produce any symptom. Computed tomography (CT) scan is diagnostic.

Late Effects of Breast Cancer Treatment and Outcome after Corrective Interventions.

Purpose: To study the late toxicities of treatment and its impact on Breast cancer survivors among Indian patients. Materials and Methods: Our study recruited 152 curatively treated non metastatic carcinoma breast patients. The baseline demographic details, disease related and treatment related information were collected. The late effects included breast cancer related lymphedema, shoulder dysfunction, treatment induced bone loss, hypothyroidism, cardiac dysfunction, and chemotherapy induced cognitive dysfunction and Quality of life. Results: The median age was 47 years (range 27 -72 years). The cumulative frequency of BCRL and shoulder dysfunction was 31.57% and 34.86% respectively. The improvement in BCRL with corrective intervention was not statistically significant. The BCRL was significantly associated with shoulder dysfunction. The frequency of loss of bone mineral density was 38.15%. There was statistically significant improvement in bone mineral density with interventions. The cumulative rate of hypothyroidism and cardiac dysfunction was 14.47 % and 2.17% respectively which improved after corrective therapy. We did not find any delayed cognitive dysfunction. There was improvement in global health, physical function, role function, fatigue, Nausea, vomiting, pain scores, insomnia, Loss of appetite, diarrhea and arm symptoms over time with intervention. Conclusion: Our study has shown that nearly half of the survivors were suffering from at least one of the late effects. The intervention helped in improving the loss of bone mineral density, hypothyroidism, cardiac dysfunction and quality of life in Breast cancer survivors.

Evaluation of Estrogen and Progesterone Receptors and Her-2 Expression with Grading in the Fine-needle Aspirates of Patients with Breast Carcinoma.

BACKGROUND: There has been a limited literature with regards to comparison between the pre-operative hormonal/Her-2 neu assessment by immunostaining on fine-needle aspiration (FNA) versus core needle biopsies (CNBs) and their correlation with grading of breast carcinoma. MATERIALS AND METHODS: Two hundred fifty FNAs and 201 CNBs from 252 patients with breast carcinoma were subjected immunocytochemical/histochemical (ICC/IHC) staining along with the grading by the Robinson cytologic and modified Scarff-Bloom-Richardson scoring systems, respectively. Depending on the material adequacy, IHC was also performed on cell blocks. Sensitivity, specificity, and predictive values of ICC were calculated. The kappa statistics was performed to see the power of the study. Cytologic versus histologic gradings were compared and analysed by percentage analysis. RESULTS: Sensitivity of ICC on FNAs for ER, PR, and Her-2neu was 49%, 28.8%, and 46%, respectively, while specificity was 84.5%, 90.6%, and 86.6%, respectively, with a fair agreement on kappa statistics. Her-2neu positivity on CNB versus FNA had a moderate agreement. Her-2neu staining of 3+ was seen in most of the Grade-2 tumours on FNA. CONCLUSIONS: Fairly reliable results on grading and hormonal/Her-2neu status are possible when ICC is performed on qualitatively superior FNA material. This is particularly useful in the management of patients in certain settings like inoperable cases.

Medical students' perception of the educational environment in a tertiary care teaching hospital in India.

Background: The educational environment perceived by students has an impact on satisfaction with the course of study and academic achievement. We aimed to analyse the perceptions of medical students about their learning environment and to provide feedback to stakeholders involved in curriculum planning and execution. Methods: We did a cross-sectional descriptive study at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry using the Dundee Ready Educational Environment Measure (DREEM) questionnaire. The DREEM inventory was administered to the undergraduate students of all semesters (n = 452). Students' perceptions of learning, perception about teachers, academic self-perceptions, perceptions of atmosphere and their social self-perceptions were measured. The scores obtained were expressed as mean (standard deviation) and analysed using t-test and 1-way ANOVA (with post-hoc comparison using Tukey test). The difference between semesters and gender was also analysed. Results: The mean (SD) global score was 122.06 (22.27), out of a maximum possible score of 200. Our students opined that teachers were knowledgeable, with this component scoring the maximum of 3.32 and, at the same time, they felt that teaching overemphasizes factual learning (1.41). Only 6 items scored <2. 'Students' perception of atmosphere' scored high among other domains (30 of 48, 62.5%). The mean global score of preclinical students (125.35 [20.43]) was better than clinical students (119.13 [23.44]; p = 0.003). Conclusion: Although the global score is more positive, we identified a few areas of concern such as overemphasis on factual learning, authoritarian teachers, the not-so-helpful existing learning strategies, vast curriculum (inability to memorize all), lack of supporting system for stressed out students and the boredom they felt in the course. These vital areas should be addressed by the stakeholders for the betterment of learning in the institute.

Tamoxifen-induced hypertriglyceridemia causing acute pancreatitis.

Tamoxifen has both antagonistic and agonistic tissue-specific actions. It can have a paradoxical estrogenic effect on lipid metabolism resulting in elevated triglyceride and chylomicron levels. This can cause life-threatening complications like acute pancreatitis. To our knowledge, very few cases of tamoxifen-induced pancreatitis have been reported in the literature. We report a case of severe hypertriglyceridemia and acute pancreatitis following tamoxifen use. A 50-year-old diabetic lady was on tamoxifen (20mg/day) hormonal therapy for breast cancer. Within 3 months of starting therapy, she developed hypertriglyceridemia and acute pancreatitis. Laboratory values include: Serum amylase 778 IU/L, total cholesterol 785 mg/dL, triglycerides 4568 mg/dL and high-density lipoproteins (HDL) 12 mg/dL. Tamoxifen was substituted with letrozole and atorvastatin started. There was a prompt reversal of the adverse effects. Effects on lipid profile must be considered while initiating tamoxifen in predisposed individuals as the consequences are life threatening.

A single-nucleotide polymorphism in the MDR1 gene as a predictor of response to neoadjuvant chemotherapy in breast cancer.

BACKGROUND: The single-nucleotide polymorphism (SNP) 3435C > T in exon 26 of the MDR1 gene has been shown to correlate with the functioning of P-glycoprotein. We studied the frequency of SNP in exon 26 of the MDR1 gene in breast cancer and its role in predicting response to neoadjuvant chemotherapy in breast cancer. PATIENTS AND METHODS: Ninety-six patients with locally advanced breast carcinoma were enrolled. Genotyping of exon 26 of the MDR1 gene was performed, and computed tomography scans were performed before and after neoadjuvant chemotherapy. Response to 3 cycles of the 5-fluorouracil/doxorubicin/ cyclophosphamide (FAC) regimen was assessed. The prevalence of SNP was compared with that of historical controls. Association of the response was compared with the genotypes. RESULTS: The frequency of genotypes was different from that of healthy sex-matched historical controls. Prevalence of TT genotype was significantly increased in breast cancer patients (P = .025). The patients with TT genotype had 2.26 times the chance of responding to neoadjuvant chemotherapy when compared with patients with the CC genotype (P = .44). CONCLUSION: Significantly higher prevalence of 3435TT genotype in exon 26 of the MDR1 gene in patients with breast cancer might suggest the possibility of increased breast cancer susceptibility. The genotypes did not show any significant association to response to chemotherapy in the population studied.

Enterocutaneous fistula due to mesh fixation in the repair of lateral incisional hernia: a case report.

Enterocutaneous fistula following mesh repair of incisional hernia is usually due to mesh erosion of the underlying viscus and presents late. We describe an early enterocutaneous fistula due to an unusual but a potential mode of bowel injury during mesh fixation. This case is reported to emphasize the need for greater attention to the technique of mesh fixation. We suggest laparoscopic guidance to prevent this serious complication in lateral Incisional hernias with ill defined edges of the defect.