Is complete pathological response truly a complete response in breast cancer?

OBJECTIVE: To check if complete pathological response in breast cancer is a good prognostic factor. METHODS: The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data from January 2012 to December 2015 of all patients who received neo-adjuvant chemotherapy and had no distant metastasis at diagnosis. Mastectomy patients were excluded. Complete pathological response was defined as no detectable tumour cell in breast and axilla on pathological examination of the resected specimen. Tumour characteristics and 5-year disease free survival and overall survival were recorded. Data was analysed using SPSS 20. RESULTS: Of the 353 patients whose data was evaluated, 91(25.8%) had complete pathological response. Mean age at diagnosis was 43±10 years. Among them, 62(68%) patients had grade III tumour, 39(42.9%) were negative for oestrogen receptor, 58(63.7%) were negative for progesterone receptor, 25(27.5%) were positive for human epidermal growth factor receptor 2, and 26(28.6%) patients were triple negative. Overall, 28((30.7%) patients had recurrence; 20(71.4%) had distant metastasis, 6(21.4%) had local recurrence, and 2(7.14%) had contralateral cancer. The 5-year disease-free survival and overall survival rates (Kaplan-Meier Survial curve) were 70% (28 patients-recurrence) and 87% (15 patients-deaths), respectively. Conclusion: Despite complete disappearance of tumour, a significant number of patients developed recurrences.

Advances in 2-substituted benzothiazole scaffold-based chemotherapeutic agents.

Targeted therapy plays a pivotal role in cancer therapeutics by countering the drawbacks of conventional treatment like adverse events and drug resistance. Over the last decade, heterocyclic derivatives have received considerable attention as cytotoxic agents by modulating various signaling pathways. Benzothiazole is an important heterocyclic scaffold that has been explored for its therapeutic potential. Benzothiazole-based derivatives have emerged as potent inhibitors of enzymes such as EGFR, VEGFR, PI3K, topoisomerases, and thymidylate kinases. Several researchers have designed, synthesized, and evaluated benzothiazole scaffold-based enzyme inhibitors. Of these, several inhibitors have entered various phases of clinical trials. This review describes the recent advances and developments of benzothiazole architecture-based derivatives as potent anticancer agents.

Imaging features of primary breast sarcoma: A case report.

Primary breast sarcoma (PBS) is a rare group of non-epithelial tumours arising from connective tissue of the breast. We report the case of a 55-year-old female who presented with rapidly increasing mass in the left breast. The mammogram showed a large high density mass occupying the whole of the left breast, while Doppler ultrasound showed a mass of increased vascularity. Diagnosis was confirmed by histopathology of ultrasound-guided biopsy. Although there are no pathognomonic imaging features of PBS, presence of a solitary large mass showing rapid growth, with circumscribed or indistinct margins without axillary lymph node involvement should raise the suspicion of sarcoma and prompt biopsy to ensure early diagnosis and treatment; particularly considering the aggressive nature of these sarcomas.

Smokeless Tobacco and Oral Potentially Malignant Disorders in South Asia: A Systematic Review and Meta-analysis.

IMPLICATIONS: More than 250 million South and South East Asians use SLT in some form. As cigarettes prices climb up all over the world, more people could potentially take up SLT, particularly in the absence of epidemiological evidence regarding the harmful effects of these products, and SLT being advocated as a means of tobacco harm reduction. Our findings are thus relevant and timely in highlighting the harmful effects of SLT use, with a potential of influencing tobacco control policies in South Asia and beyond.

MRI Features of Synchronous Masses in Known Breast Cancer Patients in Predicting Benign Versus Malignant Lesions: A Case Based Review at Tertiary Care Cancer Hospital.

Sara RehmanObjectives The purpose of this study was to determine the diagnostic accuracy of breast magnetic resonance imaging (MRI) in classifying incidental satellite masses in biopsy-proven breast cancer patients as benign or malignant masses and assessing its impact on surgical management of these patients. We also analyzed the incidence of MRI-detected lesions, which were thereafter assessed with second look ultrasound (US). Materials and Methods A retrospective study was performed on breast cancer patients presenting from August 01, 2016 to July 31, 2019, with satellite masses seen on base line MRI. Satellite masses were classified as benign and malignant based on MRI features of shape, margin, T2-weighted imaging signals, internal enhancement pattern, enhancement kinetic curves, and diffusion restriction. This was compared with results of histopathological examination. The number of MRI-detected lesions, location of the satellite mass, and type of surgery were also documented. Results Out of 400 breast cancer patients undergoing MRI breast, 115 patients had multiple masses. Histopathological diagnosis was available for 73 patients; and a total of 93 satellite masses were evaluated. There was evidence of additional masses on second look ultrasound in 21 patients. Of 72 masses classified as malignant on MRI, 58 showed malignant pathological outcome; while out of 21 masses characterized as benign on MRI, 18 turned out to be benign on histopathology. A statistically significant association was found between MRI features and pathological outcome of satellite masses ( p = 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy were 95%, 56%, 80.56%, 85.7% and 81.7%, respectively. Based on these findings, modified radical mastectomy (MRM)/mastectomy was done for 42 patients, 5 patients underwent lumpectomy limited to a single tumor, extended resection done for 14 patients, 5 underwent bilateral breast conservation surgery (BCS), BCS for contralateral breast done for 4 patients undergoing ipsilateral MRM/mastectomy, and bilateral MRM/mastectomies were performed for 2 patients. One patient was lost to follow up. Conclusion Breast MRI is the most sensitive modality for the assessment of breast cancer and plays an essential role in the detection of additional tumor foci. These findings can modify the surgical approach in these patients. However, considering the low specificity, biopsy of satellite masses is imperative to determine the most appropriate surgical plan.

Non-Hodgkin's Vaginal Lymphoma: A Rare Presentation.

Vaginal non-Hodgkin's lymphoma (NHL) is a rare entity. We report a case of a 38-year-old lady who presented with complaints of lower abdominal pain for three to four months and vaginal bleeding for one month. Her examination under general anesthesia revealed a hard vaginal mass which was biopsied and immunohistochemistry was performed. Diagnosis of diffuse B­cell NHL (DLBCL) was made. Imaging plays an important role to reach the diagnosis. Chemotherapy is the treatment of choice.

Recurrence Yield of Stereotactic Biopsy of Suspicious Calcifications After Breast Conservation Therapy.

Aim To analyze the histopathological outcome of stereotactic biopsies of newly developed suspicious calcifications at lumpectomy scar site in patients with breast conservation surgery (BCS) to determine the incidence of malignancy and the association of mammographic appearance of recurrent microcalcification and their distribution. We also determined the association of disease recurrence with the presence of calcifications in original tumor and lumpectomy resection margins with the risk of recurrence. Materials and methods This study is a retrospective review of mammograms of patients with breast cancer from 2010 to 2021 who underwent stereotactic biopsy of newly developed suspicious calcifications at scar site appreciated on annual follow-up mammogram after breast conservation surgery (BCS) with no mass on correlative ultrasound. The radiological and pathological features of the patients' primary tumor and new calcifications were obtained from the hospital's electronic patient record system. Results A total of 84 patients with breast cancer developed suspicious microcalcifications at the lumpectomy scar site detected on follow-up mammograms after BCS, and 28.6% showed malignant histopathological outcomes. All malignant cases demonstrated pleomorphic morphology. All amorphous (9.5%) and coarse heterogeneous (54.8%) calcifications were benign. The distribution pattern of recurrent malignant calcifications was grouped in 9.5%, regional in 2.4%, linear in 9.5%, and segmental in 7.1%. Calcifications in primary tumors were found in 20.2% of cases. Positive margins were found in 7.1% of these malignant cases. Statistically, there was a strong association between calcification morphology, calcification distribution, presence of calcifications on baseline mammogram, and tumor resection margins. The presence of calcifications in primary tumors and positive resection margins were identified as significant independent risk factors of malignant recurrent calcifications in the logistic regression model and marginal statistical significance in the multivariable logistic regression (MLR) model. Conclusion The interval development of pleomorphic calcifications after BCS with either linear or segmental pattern, positive resection margins, and associated calcifications in primary tumors was related to the increase in the risk of recurrence. Although amorphous and coarse heterogeneous morphology with grouped distribution showed benign outcomes, stereotactic biopsy is recommended to exclude disease recurrence in this high-risk patient population.

Extraskeletal Mesenchymal Chondrosarcoma, a Rare Entity with Unusual Metastases: A Case Report.

Introduction: Extraskeletal mesenchymal chondrosarcoma (ESMC) is rare, aggressive, and high grade malignant tumors originating from soft tissues. It carries a poor prognosis with a tendency for local recurrence and distant metastasis, necessitating long-term follow-up. The most common sites for metastasis are the lungs, bones, and lymph nodes. Meanwhile, pancreatic metastases are extremely rare. Case Description: A 35-year-old female presented with a history of wide local excision for the left upper limb mass; histopathology showed ESMC. She was on surveillance with a computed tomography scan of the thorax and magnetic resonance imaging of the left upper limb at 3-months intervals until she developed vertebral and pancreatic lesions after 6 months post-surgery. No pulmonary metastases were noted. Considering the unusual site for metastasis and to exclude the possibility of any second malignancy, bone biopsy, and endoscopic ultrasound-guided fine-needle aspiration was performed that confirmed metastases. Later she developed osseous metastases in the pelvis and femora. Practical Implication: Pancreatic metastasis from ESMC is extremely rare. In case of new visceral or osseous lesions in a patient with a past medical history of ESMC, the possibility of metastatic disease should be considered. A biopsy can be performed to confirm the diagnosis.

Intracranial and Spinal Tuberculosis: A Rare Entity.

CNS tuberculosis has a broad spectrum of disease patterns and a high risk of complications and mortality. We present a case of a 36-year-old man who was diagnosed with neurotuberculosis with intracranial and spinal tuberculomas, meningitis, and spondylodiscitis. The patient was a known case of sarcoidosis and was being managed on corticosteroids. His presenting complaints were headache, low-grade fever, severe backache, lower limb weakness, and one episode of altered sensorium. The initial diagnosis was based on imaging findings, which were confirmed with positive cerebrospinal fluid (CSF) culture for Mycobacterium tuberculosis. Imaging and clinicopathological correlation enables early diagnosis and treatment and prevents permanent neurological sequelae.

Sonographic Evaluation of Incidental Synchronous Masses in Patients with Breast Cancer: Clinical Significance and Diagnostic Workup.

OBJECTIVE: This study aimed to evaluate the diagnostic accuracy of breast ultrasonography in classifying incidental satellite masses as benign or malignant in patients with breast cancer and to assess its effect on their surgical management. MATERIALS AND METHODS: Ultrasound-guided fine needle aspiration/biopsy was performed in 288 satellite masses of 225 patients with breast cancer. Two radiologists retrospectively reviewed the sonograms of these masses and classified them as benign or malignant and compared this feature with the results of the histopathological examination. The location of the satellite mass and type of surgery were also documented. RESULTS: Of the 288 satellite masses, 139 were located in the same quadrant, 95 in different quadrants, while 54 were in the contralateral breast. Of the 123 sonographically benign masses, 106 showed benign pathological outcome, and from 165 sonographically malignant masses, 127 were found malignant on histopathology/cytology. McNemar's chi-square was 7.27 (p-value=0.007), showing statistically significant association between sonographic features and pathological outcome of satellite masses. The sensitivity, specificity, positive and negative predictive values, and accuracy were 88.2%, 73.6%, 77%, 86.1%, and 80.9% respectively. Based on these findings, 61 patients underwent lumpectomy limited to a single tumor, 52 underwent extended resection, 78 underwent mastectomy, four underwent lumpectomy for the contralateral breast, and bilateral mastectomies were performed in another four patients. Surgery was not performed in 26 patients. CONCLUSION: Although ultrasound is an effective tool for the detection and characterization of incidental satellite masses in patients with breast cancer, biopsy is imperative to ascertain the pathological diagnosis and, therefore, select the most appropriate surgical plan.

Skin Metastasis in Breast Cancer Patients; a Case Series.

Introduction: Breast cancer is the most common malignancy in women. It frequently metastasizes to bones, lungs and liver. Although rare, skin metastasis may also take place. It may also be the presenting feature of initial or recurrent breast cancer. The assessment of recurrent metastatic disease involving skin after mastectomy can be challenging because of the benign-appearing clinical presentation. The purpose of this case series was to explore the clinical and radiological presentation of skin metastasis in patients of breast cancer. Materials and Methods: This is a retrospective case series of breast cancer patients with skin lesions on chest and abdomen at the time of initial presentation, or post-treatment such as, after mastectomy or breast conservation therapy; who underwent various radiological investigations including mammography, ultrasound scan, computed tomography (CT) scan and magnetic resonance imaging from 1 May 2018 to 30 September 2019 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan. Results: A total of eight cases were identified, out of which seven were females. The most common presentation consisted of the presence of metastatic nodules which were seen in 62.5% (five out of eight) of the patients. Other features consisted of erythematous or plaque-like skin thickening on clinical examination, increased density with indistinct margins seen on a mammogram and diffuse oedematous changes in the skin with small irregular mass or infiltration into subcutaneous tissues were visualised on ultrasound and CT studies. Conclusion: Skin metastasis from breast cancer most commonly presents as nodules, although rarely they may present as plaques or diffuse skin thickening. Awareness of diverse manifestations of skin metastasis is of utmost importance in early diagnosis and management.

Imaging Characteristics of Breast Lymphoma; a Case Series.

Introduction: Breast involvement by lymphoma is rare. It can occur as a primary breast tumour or as an extranodal manifestation of the systemic disease. The imaging features of breast lymphoma (BL) are not characteristic. Biopsy is necessary for diagnosis due to non-specific imaging features. Materials and Methods: A retrospective electronic medical chart review was conducted of patients diagnosed with lymphoma of breast that underwent diagnostic radiological procedures (including mammography, ultrasound breast, computed tomography (CT) scan and positron emission tomography (PET/CT) scan from 1 July 2018 to 31 March 2019 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan. Results: Four patients were identified. On mammogram, the most common finding consisted of the presence of high-density masses with circumscribed or indistinct margins. On ultrasound, hypoechoic masses and indistinct diffuse infiltrative patterns were observed. PET/CT and CT were helpful in detecting extramammary sites of disease and for classifying the disease into primary or secondary BL. Conclusion: The early diagnosis of the BL is important. The radiologists should include lymphoma in the differential diagnosis when there is the absence of microcalcifications or spiculated margins on mammography and ultrasound.

Smokeless tobacco and oral potentially malignant disorders in South Asia: a protocol for a systematic review.

INTRODUCTION: Oral potentially malignant disorders (OPMDs) are chronic lesions or conditions characterized by a potential for malignant transformation. Apart from being possible pre-cursors to oral cancer, OPMDs themselves are usually painful and debilitating conditions having an influence on the quality of life, both in terms of pain and social disability. Smokeless tobacco (SLT) use is considered a major risk factor for OPMDs. SLT use is a culturally and socially acceptable habit in South Asia. According to a recent report, 90 % of the SLT burden of the whole world lies in the South Asian countries of Pakistan, India, Sri Lanka, Bangladesh, Bhutan, Nepal, Afghanistan, and Maldives. This review aims to assess the association between the use of various SLT products in South Asia and risk of OPMDs. METHODS: This review will focus on epidemiological studies on the use of SLT and risk modification for OPMDs, which have been carried out in the human population of South Asian countries. Articles reporting estimates of relative risk, e.g., odds ratio (OR) or relative risk (RR) with their 95 % confidence intervals (CI) for SLT users versus non-users. Articles reporting data from which these effect estimates can be computed will be included in the review. We will search MEDLINE, the Science Citation Index (SCI), Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for relevant literature using a combination of keywords and MeSH terms, where applicable. Appropriate sources of gray literature will also be included in the search. The electronic searches will be supplemented by a hand search of the bibliographies of the included articles. The included studies will be assessed for their quality using an established quality assessment tool. All relevant data from the included articles will be recorded in an MS Excel spread sheet and then transferred to Rev Man 5.3 to carry out a meta-analysis. Heterogeneity among the estimates will be assessed through the I (2) statistic. Sensitivity and subgroup analysis will be carried out to see the effects of individual or group of studies on the pooled effect estimate. Results of the review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. DISCUSSION: This review may have a potential limitation with regard to the designs of the studies included as we expect that most of the included studies will be of the observational types. We will however try to address this issue by conducting sensitivity and subgroup analysis of similar quality studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015029705 .

Fructose intake and risk of gout and hyperuricemia: a systematic review and meta-analysis of prospective cohort studies.

BACKGROUND: The prevalence of hyperuricemia and gout has increased in recent decades. The role of dietary fructose in the development of these conditions remains unclear. OBJECTIVE: To conduct a systematic review and meta-analysis of prospective cohort studies investigating the association fructose consumption with incident gout and hyperuricemia. DESIGN: MEDLINE, EMBASE and the Cochrane Library were searched (through September 2015). We included prospective cohort studies that assessed fructose consumption and incident gout or hyperuricemia. 2 independent reviewers extracted relevant data and assessed study quality using the Newcastle-Ottawa Scale. We pooled natural-log transformed risk ratios (RRs) using the generic inverse variance method. Interstudy heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: 2 studies involving 125 299 participants and 1533 cases of incident gout assessed the association between fructose consumption and incident gout over an average of 17 years of follow-up. No eligible studies assessed incident hyperuricemia as an outcome. Fructose consumption was associated with an increase in the risk of gout (RR=1.62, 95% CI 1.28 to 2.03, p<0.0001) with no evidence of interstudy heterogeneity (I2=0%, p=0.33) when comparing the highest (>11.8% to >11.9% total energy) and lowest (<6.9% to <7.5% total energy) quantiles of consumption. LIMITATIONS: Despite a dose-response gradient, the overall quality of evidence as assessed by GRADE was low, due to indirectness. There were only two prospective cohort studies involving predominantly white health professionals that assessed incident gout, and none assessed hyperuricemia. CONCLUSIONS: Fructose consumption was associated with an increased risk of developing gout in predominantly white health professionals. More prospective studies are necessary to understand better the role of fructose and its food sources in the development of gout and hyperuricemia. PROTOCOL REGISTRATION NUMBER: NCT01608620.

Spontaneous resolution of a branchial cleft cyst without intervention: a previously unreported outcome.

Branchial cleft cysts typically present as a persistent mass in the anterior triangle of the neck. Diagnosis is made by imaging and fine needle aspiration cytology and is confirmed histologically after excision. We report a branchial cleft cyst in a 27-year-old woman that resolved spontaneously over several weeks without surgical intervention. To the best of our knowledge this is the first report of such a case.