Pooja Ramakant

Breast Cancer Care in Developing Countries

BackgroundBreast cancer is the commonest cancer of women the world over, and its incidence is rising, especially in developing countries, where the disease poses a major health care challenge. This growing incidence in developing countries reflects the advanced stage at diagnosis, low levels of public awareness of the risk for the disease, and poor medical infrastructure and expertise, with the resultant poor treatment outcomes.MethodsThis article provides a collective edited summary of the presentations at the symposium titled “Breast Cancer Care in Developing Countries,” held as part of the Breast Surgery International program at the International Surgical week 2007, Montreal, Canada, August 2007. The aim of the presentations was to bring out the diverse clinical pathological and outcomes-related facts of breast cancer care available to women in several countries. As the incidence of breast cancer continues to rise steadily in the developing world, the lack of awareness of this disease and the absence of breast cancer screening programs make it almost certain that the majority of breast cancers are diagnosed at an advanced stage. In addition, the quality of care available for breast cancer patients varies widely according to where the patient is treated.ResultsThough there are some centers of excellence providing multimodality protocol-based treatment on a par with the best anywhere in the world, most breast cancer patients receive inadequate and inappropriate treatment because of a lack of high-quality infrastructure—and sometimes skills—and, above all, because of limited financial resources.ConclusionsIn countries where these limitations are present, there is a need to emphasize public health education, promoting early diagnosis. In addition, resources must be directed toward the creation of more public facilities for cancer treatment. As these goals are met, it is likely that there will be a much-needed improvement in breast cancer care in developing countries.

Pheochromocytoma Screening Initiation and Frequency in von Hippel-Lindau Syndrome

CONTEXT Patients with von Hippel-Lindau (VHL) syndrome have a 25-30% chance of developing pheochromocytoma. Although practice guidelines recommend biochemical and radiological screening every 1-2 years for pheochromocytoma in patients with VHL, there are limited data on the optimal age and frequency for screening. OBJECTIVE Our objective was to determine the earliest age of onset and frequency of contralateral and recurrent pheochromocytomas in patients with VHL syndrome. METHODS This is a retrospective analysis of a prospective cohort of patients with VHL enrolled in a natural history study. RESULTS A total of 273 patients diagnosed with VHL were enrolled in a natural history clinical study. Thirty-one percent (84) were diagnosed with pheochromocytoma. The mean age of diagnosis was 28.8 ± 13.9 years. The earliest age at diagnosis was 5.5 years. Median follow-up for the cohort was 116.6 months (range, 0.1-613.2). Ninety-nine percent (83) of patients underwent adrenalectomy. Fifty-eight and 32% of patients had metanephrines and/or catecholamines elevated more than two times and more than four times the upper limit of normal, respectively. Twenty-five percent (21) of pheochromocytomas were diagnosed in pediatric patients younger than 19 years of age, and 86% and 57% of pediatric patients had an elevation more than two times and more than four times upper limit of normal, respectively. Eight patients had a total of nine recurrences. The median age at recurrence was 33.5 years (range, 8.8-51.9). Recurrences occurred as short as 0.5 years and as long as 39.7 years after the initial operation. CONCLUSIONS Our findings among VHL pediatric patients supports the need for biochemical screening starting at age 5 with annual lifelong screening.

Challenges in management of phyllodes tumors of the breast: A retrospective analysis of 150 patients

INTRODUCTION Phyllodes tumors (PT) of the breast seem to get pre-operatively misdiagnosed as fibroadenomas resulting in inadequate resections and high local recurrence rates. MATERIALS AND METHODS Data of 150 patients with PT of the breast managed from January, 2003 to February, 2013 were retrospectively analyzed. Statistical analysis performed using SPSS version 17 (Pearson Chi-square test and analysis of variance test for analysis). AIM The aim of this study is to compare clinico-pathological profile and recurrence rates in patients with benign (B), borderline malignant (BL) and malignant (M) PT. RESULTS In a total of 150 patients with PT (n = 77 B, n = 24 BL, n = 49 M), mean age was 36.92, 44.04 and 40.46 years respectively (P 0.015) and mean tumor size being 8.15 cm, 14.7 cm and 12.9 cm respectively (P 0.000). Pre-operatively cytology suggestive of PT in 24% patients with B PT and 63% in M PT; core tissue biopsy suggestive of PT in 85.4% patients with B PT and 100% in M PT. Recurrence seen in 34.7% out of which 32.7% were post-lumpectomy performed elsewhere. Majority of B PT had lumpectomy (49.3%)/wide local excision (WLE, 31.2%) compared with M PT where 55.1% had simple mastectomy (SM) due to large tumor size. Local recurrence was more in M PT (53%) compared with B PT (20%). We found recurrence rates in L (39.3%) compared with WLE (27.3%) and SM (33.9%) (P 0.049). CONCLUSIONS Larger tumor size, incomplete resection and M/BL histology predicted higher recurrence in PT. Core biopsy is much more accurate than fine needle cytology in the diagnosis.

Preoperative Ultrasonography Assessment of Vocal Cord Movement During Thyroid and Parathyroid Surgery

Wereadwithinterestthearticle‘‘Preoperativeultrasonographyassessment of vocal cord movement during thyroid andparathyroid surgery’’ by Cheng et al. [1]. We congratulate theauthors on using a noninvasive modality for evaluating vocalcords preoperatively with no added cost or time. It was apatient-friendly initiative in a resource-constrained environ-ment. Patients with vocal cord palsy may be asymptomatic.Indirect laryngoscopy is not adequate in all cases. If it isperformed routinely, it becomes costly, as do visits tooutpatient clinics. There is also patient discomfort to beconsidered as it is an invasive procedure. ENT surgeons arenot widely available; and even if available, these patientsare not a priority. The cost incurred, the discomfort for thepatient, and the physician’s expertise are issues associatedwith performing regular fiberoptic bronchoscopy. Thequestion of attending surgeons performing indirect laryn-goscopy in terms of medicolegal purposes continues to beconsidered by many surgical societies. If the same logisticsare adopted for ultrasonography, the question arises whe-ther it would be more prudent to have the vocal cordexamined by radiologists. We have a few queries related tothe present study [1–6].Nonrecurrent laryngeal nerves are rare [2]. Did the Ysign done for evaluation increase the time taken to performultrasonography (USG)? Did the authors use USG forperforming guided fine-needle aspiration cytology? Werethe vocal cords evaluated postoperatively with USG? Ifyes, then what was the sensitivity and specificity of USGpostoperatively [4]? Was pulsed Doppler used to quantifythe tissue displacement velocity in the vibrating vocal foldsection [3]? Did the authors perform the Valsalva maneu-ver to adduct the vocal cords? Did the severe sniffing resultin displacement of the probe, thereby causing difficultywhen performing USG?References

Role of cortical sparing adrenalectomy and novel variant of mutation in patient with von Hippel-Lindau disease.

Neurofibromatosis type 1 is the most common phakomatoses and is inherited in autosomal dominant fashion with complete penetrance. Secondary hypertension is common in these patients due to various causes including adrenal tumors. Pheochromocytoma is a rare catecholamine producing tumor seen in 0.5% to 5% of patients with neurofibromatosis. The combination of pheochromocytoma with neurofibromatosis is rarely reported in the literature. We recently encountered an elderly lady with this combination who successfully underwent adrenalectomy. We report the case for the uncommon occurrence and to highlight the relevant literature review about pheochromocytoma in neurofibromatosis.

Acute suppurative thyroiditis secondary to urinary tract infection by E. coli: a rare clinical scenario.

A 60-year-old woman with diabetes and symptomatic urinary tract infection presented to us with a painful neck swelling for 2 weeks. We discuss diagnostic and management issues in acute suppurative thyroiditis caused by Escherichia coli.

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.

Adrenal Teratoma: Unusual Tumor with Typical Imaging Characteristics

Teratomas per se are rare and retroperitoneal teratomas are a still rarer entity. We report the image of a patient who presented with a large adrenal teratoma which was nonfunctional biochemically and who underwent surgical excision. The imaging characteristics are suggestive of teratoma and must be kept in mind while managing large adrenal tumors.

Surgical Techniques for Dealing with Intraluminal Thrombus of Great Vessels in Advanced Differentiated Thyroid Carcinoma

Aim: We aim to define and refine the surgical technique for dealing with intraluminal thrombus of great vessels in advanced differentiated thyroid carcinoma (DTC) to reduce the morbidity. Background: Venous tumor thrombus from DTC is a rare occurrence with sequelae that cause increased morbidity and early mortality. Management of such patients poses a challenge to surgeons. Materials and methods: We define the surgical planning and road map for surgical management of advanced DTC with tumor thrombus involving the internal jugular vein (IJV) and superior vena cava (SVC) by sacrificing one IJV and retrieving the thrombus from the SVC by Fogarty catheter. This technique has minimal morbidity with good outcome. Conclusion: By appropriate planning and meticulous surgical techniques, we can aggressively manage patients of advanced DTC with venous tumor thrombus and reduce the morbidity. Clinical significance: By surgical techniques leading to complete surgical resections and saving native vital structures, we can aim for successful aggressive surgical management of advanced DTC with venous tumor thrombus.

Serum phosphorus values for early prediction of hypocalcemia in total thyroidectomy

I read with interest article by Inversini et al. (1) in October issue. Hypocalcaemia is most dreaded complication after thyroidectomy and we agree with authors. There is also ample evidence in literature for postoperative parathyroid hormone (PTH) use to predict the risk of hypocalcaemia after thyroidectomy. However it is not possible to have PTH estimation in all patients in third world hospitals where either the facility is not available or all patients cannot afford. In India, almost all government medical college hospitals provide treatment free or at minimum cost which includes admission, bed, operation and bed charges, including meals. Thyroid surgery is practised by specialists as a day care surgery but we keep the patient in hospital for at least two days for hypocalcaemia monitoring. Here day care means that these patients are off fluid and orally allowed with eight hours. Thyroidectomy patient is kept in the hospital for two post-operative days as there is no bed charge. We always want to discharge our patients earlier not because of cost factor but because of patient load and waiting. PTH estimation is not available in all government hospital but calcium and phosphorus is available free of cost.