Rajeev Kumar Seam

Knowledge of Risk Factors & Early Detection Methods and Practices towards Breast Cancer among Nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

BACKGROUND Breast cancer is an increasing health problem in India. Screening for early detection should lead to a reduction in mortality from the disease. It is known that motivation by nurses influences uptake of screening methods by women. This study aimed to investigate knowledge of breast cancer risk factors and early detection methods and the practice of screening among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh. MATERIALS AND METHODS A cross-sectional study was conducted using a self-administered questionnaire to assess the knowledge of breast cancer risk factors, early detection methods and practice of screening methods among 457 nurses working in an Indira Gandhi Medical College, Shimla-H.P. Chi square test, Data was analysed using SPSS version 16. Test of significance used was chi square test. RESULTS The response rate of the study was 94.9%. The average knowledge of risk factors about breast cancer of the entire population is 49%. 10.5% of nurses had poor knowledge, 25.2% of the nurses had good knowledge, 45% had very good knowledge and 16.3% of the nurses had excellent knowledge about risk factors of breast cancer and early detection methods. The knowledge level was significantly higher among BSC nurses than nurses with Diploma. 54% of participants in this study reportedly practice BSE at least once every year. Less than one-third reported that they had CBE within the past one year. 7% ever had mammogram before this study. CONCLUSIONS Results from this study suggest the frequent continuing medical education programmes on breast cancer at institutional level is desirable.

Thyroid scintigraphy in detecting dual ectopic thyroid: A review

Dear Sir, The thyroid gland is the first endocrine gland to develop during embryogenesis on approximately 24th day of gestation. The developing thyroid is anatomically related to the developing heart, and it is pulled caudally to its definitive location in the anterior neck with the descent of heart. The thyroid completes its descent on reaching anterior to the trachea in the lower neck in the seventh gestational week. The development defects or aberrant migration of the thyroid descent will lead to ectopy of the thyroid. The Foxe 1 mutation is also shown to be associated with molecular pathology of ectopic thyroid in mouse models; however, till date, no known gene for human ectopic thyroid has been demonstrated [1]. An ectopic thyroid gland may occur anywhere along the path of initial descent of the thyroid. The most commonly found ectopic thyroid tissue is at the base of the tongue, i.e. lingual thyroid, which accounts for 90% of the reported cases. Other rare sites for ectopic thyroid are the sublingual, cervical, mediastinal, intracardiac and abdomen [2]. Most of the times, ectopic thyroid might be the only functioning thyroid tissue. Ectopic thyroid is a rare anomaly. It is further uncommon for two distinct ectopic thyroid tissues to be present simultaneously. The web search of Pubmed in English literature revealed only 26 cases of dual ectopic thyroid so far. In this letter, we describe a patient of dual ectopic thyroid where the Tc-pertechnetate thyroid scan clinched the diagnosis and led to correct management. The literature available on dual ectopic thyroid tissue is also being discussed. A 7-year-old girl presented with history of progressive midline swelling of the neck for 1 year. There was no history of pain, fever, pressure or obstructive symptoms and change in voice. Patient did not have any feature of hypo-thyroidism or hyper-thyroidism. Local examination revealed a midline neck swelling of 1.5×1 cm in size, soft in consistency, non-translucent in nature, which moved on tongue protrusion and swallowing. The oral examination showed another small irregular swelling of about 1 cm size near the base of the tongue, which was soft to firm on touch and non-tender (Fig. 1). Her thyroid function tests were suggestive of sub-clinical hypo-thyroidism with value of T3—75 ng/dL (normal=75–210), T4—4.30 μg/dL (normal=4–11) and thyroid-stimulating hormone (TSH)— 17.88 μIU/mL (normal=0.55–5.0). Based on clinical and biochemical examination, a diagnosis of ectopic thyroid was made, and the patient was referred for thyroid scan for confirmation. The thyroid Tc-pertechnetate scan demonstrated two distinct focal areas of radiotracer uptake in the sublingual and subhyoid region and no uptake in region of the thyroid bed (arrows; Fig. 2). A final diagnosis of dual ectopic thyroid was made based on thyroid scan findings. Eur J Nucl Med Mol Imaging (2008) 35:843–846 DOI 10.1007/s00259-007-0672-2

Concurrent chemoradiation in locally advanced carcinoma cervix patients.

PURPOSE To investigate the feasibility of concurrent chemo radiation in locally advanced carcinoma cervix patients in our clinical setting. MATERIALS AND METHODS From Sept. 1st 2005 to Aug. 31st 2006, 102 patients of carcinoma cervix belonging to stage IIA to IV A were enrolled in the study. External beam radiation therapy was administered using Cobalt 60 teletherapy machine. Cisplatinum (40 mg/m 2) and 5 Fluorouracil (500 mg/m 2 ) continuous infusions with radiotherapy on D2-D5 in first and last 5 # of radiation therapy were administered. RESULTS Response to treatment and toxicities were monitored and analyzed in 102 patients (50 study group and 52 control group). All 102 patients completed treatment. Out of 50 patients in the study group, 30, 10 and 4 patients had complete, partial and progressive disease, respectively. While out of 52 patients in the control group, 26 had complete and 12 showed partial response. No difference in overall renal, hematological and cutaneous toxicity was seen between two groups. CONCLUSION This study did not show any benefit of concurrent chemo radiation as compared to radiotherapy alone in locally advanced cervical cancer patients. This could be due to more bulk of tumor stage per stage, poor nutritional status, less number of patients in both arms, not enough to pick up statistically significant small difference in outcome.

Role of scintimammography in assessing the response of neoadjuvant chemotherapy in locally advanced breast cancer.

Locally advanced breast cancer (LABC) is a common cancer in the developing countries. Neoadjuvant chemotherapy (NACT) is a very important step in the treatment of such tumors and hence that the disease can be down staged and made amenable for surgery. All the tumors do not respond to the therapy equally. Hence, it becomes very important to predict the response of chemotherapy in such cases. This study evaluated the role of scintimammography in assessing the response to NACT in 23 patients with LABC. Histologically proven 23 patients of LABC were recruited in this study. Prechemotherapy tumor size was measured clinically in all patients and technitium (Tc)-99m sestamibi test was performed before NACT for each patient. Early (10 min) and delayed (2 h) image of the breast were acquired in anterior and lateral views after Tc-99m sestamibi intravenous injections and wash out rate (WOR) was computed. After 3-4 cycles of chemotherapy, surgery in the form of modified radical mastectomy was performed in 20 out of 23 patients (3 patients lost to follow-up) with pathologic evaluation of the residual tumor size. The pretherapy Tc-99m sestamibi WOR ranged from 8.3% to 68% with mean ± SD of 34.5% ±16.5%. The prechemotherapy Tc-99m sestamibi study predicted chemoresistance (WOR >45%) in 6 out of 20 patients and no chemoresistance (WOR <45%) in 14 out of 20 patients. When the WOR cut-off was set at >45%, the predictivity of the test was indicated by sensitivity of 91.7%, specificity of 62.5%, positive predictive value of 78.6%, and negative predictive value of 82.3% with a likelihood ratio of 0.1. Tc-99m sestamibi WOR is a reliable test for predicting tumor response to NACT. WOR >45% is highly predictive of chemoresistance with likelihood ratio of 0.1 than WOR <45% being predictive of chemoresponsiveness.

Diffuse hepatic and splenic Tc-99m MDP tracer uptake in case of multiple myeloma

Tc-99m methylene diphosphonate (MDP) bone scintigraphy has long been used for the evaluation of benign as well as malignant skeletal conditions. However, non-osseous tracer uptake on a bone scan is an unusual finding. There is a need to understand the pathophysiological basis of the non-osseous uptake, which may have a clinical relevance or deteriorating effect on the quality of the bone scan. We describe a case of multiple myeloma, where extraosseous uptake in the form of diffuse hepatic and splenic uptake, with almost normal skeletal tracer distribution, has been seen on the bone scan.

Undue delay in the diagnosis of lung cancer due to the clinician’s preoccupation with pre-existing tuberculosis

The authors report the case of a seminomadic older patient who had already received a course of antitubercular treatment and within a few weeks of completion suffered resurgence of symptoms. His treating physician assumed it to be relapse of tuberculosis and hence re-started the patient on antitubercular treatment. Though the mass lesion on CT scan procured by the primary care physician suggested the possibility of a neoplasm, areas of necrosis within the mass led to a ‘cavitary appearance’, which unfortunately happens to be a feature of tuberculosis. Once the patient presented to the authors, they performed cytological investigations which established that the patient had lung cancer co-existing with tuberculosis, which indeed was the reason for his progressive symptoms in spite of antitubercular treatment.

Müllerian duct anomalies and their effect on the radiotherapeutic management of cervical cancer.

Radiotherapy plays a major role in the treatment of cervical cancer. A successful radiotherapy program integrates both external beam and brachytherapy components. The principles of radiotherapy are strongly based on the anatomy of the organ and patterns of local and nodal spread. However, in patients with distorted anatomy, several practical issues arise in the delivery of optimal radiotherapy, especially with brachytherapy. Müllerian duct anomalies result in congenital malformations of the female genital tract. Though being very commonly studied for their deleterious effects on fertility and pregnancy, they have not been recognized for their potential to interfere with the delivery of radiotherapy among patients with cervical cancer. Here, we discuss the management of cervical cancer among patients with Müllerian duct anomalies and review the very sparse amount of published literature on this topic.

Sclerosing stromal tumour of the ovary

Abstract Sclerosing stromal tumours (SSTs) are rare, benign, sex cord stromal tumours of the ovary. They affect women, who complain mainly of menstrual irregularity, in their second and third decades. We report a histologically confirmed case of a 23-year-old woman who presented with complaints of abdominal pain and irregular menstruation. She later underwent surgery when a pre-pathology workup raised the suspicion of a malignant tumour. It is imperative to consider the differential diagnosis of an SST of the ovary in a young woman with an ovarian tumour.

When Palliative Treatment Achieves More Than Palliation: Instances of Long-term Survival after Palliative Radiotherapy.

Context: Palliative radiotherapy aims at symptom alleviation and improvement of quality of life. It may be effective in conferring a reasonable quantum of local control, as well as possibly prolonging survival on the short term. However, there can be rare instances where long-term survival, or even cure, results from palliative radiotherapy, which mostly uses sub-therapeutic doses. Aim: To categorize and characterize the patients with long-term survival and/or cure after palliative radiotherapy. Materials and Methods: This study is a retrospective analysis of hospital records of patients treated with palliative radiotherapy from 2001 to 2006 at the Regional Cancer Centre, Shimla. Results: Of the analyzed 963 patients who received palliative radiotherapy, 2.4% (n = 23) survived at least 5 years, with a large majority of these surviving patients (73.9%, n = 17) being free of disease. Conclusions: In addition to providing valuable symptom relief, palliative radiotherapy utilizing sub-therapeutic doses may, in a small proportion of patients, bestow long-term survival, and possibly cure. Rationally, such a favorable, but rare outcome cannot be expected with supportive care alone.

Dermatomyositis and chest radiography leading to the diagnosis of lung cancer and subsequent confusions in staging due to the presence of tuberculosis

This clinical scenario describes dermatomyositis as a presenting feature of carcinoma of the lung. However, the coincident existence of tuberculosis in the opposite lung gave rise to a false impression of contralateral lung metastasis and hence confusions with regard to staging ensued, which were clarified after further investigation confirmed a unilateral lung adenocarcinoma and contralateral tuberculosis. The patient was initiated on oral antiepidermal growth factor receptor therapy with erlotinib, as well as on multi-drug therapy for tuberculosis. This report intends to illustrate that paraneoplastic syndromes such as dermatomyositis can be the presenting feature of lung cancer, and also that the co-incident presence of carcinoma and tuberculosis can cause confusions with regard to staging and management.