Anita Dhar

Role of Centchroman in Regression of Mastalgia and Fibroadenoma

ObjectivesCentchroman (Ormeloxifene) is a novel non-steroidal, selective antiestrogen. Because of its selective antiestrogen action, centchroman has been used for treatment of mastalgia and fibroadenoma.Materials and MethodsBenign breast disease patients up to 35 years of age attending our surgery outpatient department from August 2003 to September 2004 and fulfilling the inclusion criterion were included in this study. They were started on centchroman 30 mg on alternate days for a period of 3 months and were followed up for 6 months. Results were recorded as per clinical examination, visual analog scale (VAS) for pain, and ultrasonography for breast lump size.ResultsA total of 60 patients were included in this pilot study, 42 (70%) of whom had mastalgia with or without nodularity, and 18 (30%) had fibroadenoma. Noncyclical pain was recorded in 38 patients (90%), and cyclical pain was recorded in only 4 (10%) patients. A VAS score of 10 was recorded by 33 (80%) patients (severe pain), and the remaining 9 patients (20%) had VAS scores from 7 to 10. Fibroadenoma size ranged from 1.5 to 5 cm., single or multiple in one or both breasts. There was a good response in the mastalgia group, with a decrease in the VAS scoring from 10 to 3 in 90 % of the patients in the first week. Almost all of the patients were painless at the end of one month, with complete disappearance of the nodularity. In the fibroadenoma group there was a mixed response, with complete disappearence in 40%, partial regression in 20%, and no response at all in the remaining 40%. There were very few side effects.ConclusionsCentchroman is a safe nonsteroidal drug for the treatment of mastalgia and fibroadenoma. It has shown good results in mastalgia and is a safe drug as compared to the drugs of choice used at present (danazole and bromocriptine). Further randomized studies are in progress and are needed to determine its definitive role in this patient group.

Evaluation of Xpert MTB/RIF assay performance in diagnosing extrapulmonary tuberculosis among adults in a tertiary care centre in India

To the Editor: According to the World Health Organization Global Tuberculosis Report from 2013, there were 8.6 million incident tuberculosis (TB) cases globally and India alone contributed 26% to this global scenario [1]. Of the five countries with the largest number of TB incident cases in 2012, India tops the list [1]. Epidemiological data suggest that extrapulmonary TB (EPTB) constitutes about 15–20% of all TB cases, but among HIV-TB co-infection it accounts for 50% of the cases [2]. Out of 1 183 373 new TB cases notified globally, 234 029 (20%) were reported to be cases of EPTB [1]. Difficulty in sampling from the extrapulmonary sites and the paucibacillary nature of the specimens make EPTB a diagnostic challenge. Dependency on smear microscopy in these samples may lead to higher false negative rates due to the low sensitivity of this technique. Mycobacterium tuberculosis (MTB) culture is quite a protracted technique, requiring well-trained laboratory personnel, and delay in diagnosis can cause more harm as the treatment is often started empirically. Rapid nucleic acid amplification tests are emerging extensively to provide better yield for rapid diagnosis of TB. The Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) is an automated, hemi-nested real-time PCR for detecting MTB complex and rifampin (RIF) resistance, which was initially evaluated for pulmonary specimens in large studies [3–5]. The present communication reports the performance of Xpert MTB/RIF in EPTB samples, with a large sample size from a single centre in a country with a high TB burden. All EPTB samples from indoor as well as outdoor facilities of the All India Institute of Medical Sciences (AIIMS) hospital, New Delhi, India, were received in the Tuberculosis Laboratory (accredited Intermediate Reference Laboratory …

Administration of Adult Human Bone Marrow-Derived, Cultured, Pooled, Allogeneic Mesenchymal Stromal Cells in Critical Limb Ischemia Due to Buerger’s Disease: Phase II Study Report Suggests Clinical Efficacy

Critical limb ischemia (CLI) due to Buerger’s disease is a major unmet medical need with a high incidence of morbidity. This phase II, prospective, nonrandomized, open‐label, multicentric, dose‐ranging study was conducted to assess the efficacy and safety of i.m. injection of adult human bone marrow‐derived, cultured, pooled, allogeneic mesenchymal stromal cells (BMMSC) in CLI due to Buerger’s disease. Patients were allocated to three groups: 1 and 2 million cells/kg body weight (36 patients each) and standard of care (SOC) (18 patients). BMMSCs were administered as 40–60 injections in the calf muscle and locally, around the ulcer. Most patients were young (age range, 38–42 years) and ex‐smokers, and all patients had at least one ulcer. Both the primary endpoints—reduction in rest pain (0.3 units per month [SE, 0.13]) and healing of ulcers (11% decrease in size per month [SE, 0.05])—were significantly better in the group receiving 2 million cells/kg body weight than in the SOC arm. Improvement in secondary endpoints, such as ankle brachial pressure index (0.03 [SE, 0.01] unit increase per month) and total walking distance (1.03 [SE, 0.02] times higher per month), were also significant in the group receiving 2 million cells/kg as compared with the SOC arm. Adverse events reported were remotely related or unrelated to BMMSCs. In conclusion, i.m. administration of BMMSC at a dose of 2 million cells/kg showed clinical benefit and may be the best regimen in patients with CLI due to Buerger’s disease. However, further randomized controlled trials are required to confirm the most appropriate dose. Stem Cells Translational Medicine 2017;6:689–699

Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: a prospective cohort study.

BACKGROUND The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double - blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self-assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter-class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P < 0.05). Moreover, 96% of patients were moderately to extremely satisfied with the surgery. Patients were offered an option for cosmetic correction of contralateral breast by mastopexy or reduction mammoplasty however, none of them agreed for another procedure. CONCLUSIONS Oncoplastic breast surgery helps to resect larger volume of tissue with wider margins around the tumor. It helps to achieve better cosmesis and extends the indications for breast conservation. Most of the patients were satisfied with mere preservation of the breast mound rather than a symmetrical contralateral breast.

Bleeding Scrotal Vascular Lesions: Interventional Management with Transcatheter Embolization

Vascular lesions of the scrotum are uncommon; the most common among them are varicocele lesions. The other vascular lesions that may involve the scrotum are hemangioma, lymphangioma, and arteriovenous malformations, which are exceedingly rare. The imaging modalities useful in the diagnosis and management of scrotal vascular lesions are grayscale sonography, color Doppler sonography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. We present two cases of scrotal vascular lesions involving the extratesticular scrotal soft tissues. Patients presented with bleeding and were treated by radiological interventional technique. We emphasize the importance of superselective catheterization and distal embolization.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer.

BACKGROUND In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND). AIMS This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis. SETTINGS AND DESIGN Cross-sectional study of 40 breast cancer patients. MATERIALS AND METHODS Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation. RESULTS SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13). STATISTICAL ANALYSIS We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate. CONCLUSION Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Role of fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography in the evaluation of axillary lymph node involvement in operable breast cancer in comparison with sentinel lymph node biopsy

Purpose: Role of (18 [F] fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose [FDG] positron emission tomography-computed tomography [PET-CT]) in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer and compare results with sentinel lymph node biopsy (SLNB). Methods: A total of 37 patients of proven T1T2N0 breast cancer were included in the study. Patients with past history of breast surgery, T3T4 disease, uncontrolled diabetes mellitus and pregnant patients were excluded from the study. Pre-operative FDG PET-CT was performed followed by sentinel lymph node (SLN) biopsy with blue dye or combined technique. Results: SLN was identified in 32 of 37 patients with an identification rate of 86.48% (32/37). With combined technique SLN identification rate was 100% (6/6) while with blue dye alone; it was 83.8% (26/31). Among 37 patients, 16 had axillary metastases of which 12 had macrometastases and four had micrometastases detected by immunohistochemistry (IHC). Of 12 patients with axillary macrometastases, skip metastases were present in two patients in whom SLN was negative and in two patients SLN was not identified, but axillary dissection showed metastases. PET-CT had shown sensitivity, specificity, negative predictive value and positive predictive value of 56%, 90%, 73%, and 81.8%, respectively. IHC of SLN detected four patients with micrometastases upstaging the disease by 11% (4/37). Conclusion: Because FDG PET-CT has a high specificity in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer patients according to the results of this study if FDG PET-CT is positive in axillary lymph nodes, axillary lymph node dissection may be considered instead of SLNB.

Sentinel lymph node mapping in early breast cancer — Our experience

BackgroundThe axillary lymph node status is the most important determinant of prognosis in patients with breast cancer. Sentinel lymph node (SLN) biopsy is a safe alternative for axillary clearance with an equal efficacy limiting the morbidity caused by axillary clearance.Patient and methodsFrom May 1996 till September 2009, 523 clinically node negative, early breast cancer patients attending our clinic at All India Institute of Medical Sciences were included in the study. They underwent sentinel lymph node biopsy by either combined technique or blue dye alone. All patients irrespective of the axillary status underwent axillary lymph node dissection (ALND).ResultsOf 523 patients, 267 underwent combined technique of sentinel node mapping and 256 underwent blue dye technique alone. The identification rate of sentinel lymph node was 94.3% (253/267) for combined technique and 87.8% (225/256) for blue dye alone. Of 523 patients SLN was identified in 478 patients. The identification rate was 91.3%. The sensitivity = 91.5% (141/154), false negative = 8.4% (13/154), negative predictive value = 96.14% (324/337), and accuracy being 97.2% (465/478).ConclusionSentinel node mapping is a simple and safe technique of identifying the axillary node involvement. Sentinel lymph node biopsy is associated with less arm oedema and shoulder morbidity compared to ALND. However, the results of long term effects of sentinel node approach on tumor recurrence or patient survival are awaited.

Mycetoma sans sinuses

Mycetoma is a chronic suppurative infection involving the skin, subcutaneous tissue and bone. The hallmark of mycetoma is tumefaction, draining sinuses and the presence of microcolonies called grains. Sinuses develop in all patients with mycetoma within a year of the appearance of the lesion. The following case is reported as no sinuses had developed despite the presence of the lesion for 9 years, posing a diagnostic dilemma.

OSCE as a Summative Assessment Tool for Undergraduate Students of Surgery—Our Experience

Traditional examination has inherent deficiencies. Objective Structured Clinical Examination (OSCE) is considered as a method of assessment that may overcome many such deficits. OSCE is being increasingly used worldwide in various medical specialities for formative and summative assessment. Although it is being used in various disciplines in our country as well, its use in the stream of general surgery is scarce. We report our experience of assessment of undergraduate students appearing in their pre-professional examination in the subject of general surgery by conducting OSCE. In our experience, OSCE was considered a better assessment tool as compared to the traditional method of examination by both faculty and students and is acceptable to students and faculty alike. Conducting OSCE is feasible for assessment of students of general surgery.