Subhash Ramani

A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster‐randomized, controlled, screening‐trial for cervix and breast cancer using trained primary health workers to provide health‐education, visual‐inspection of cervix (with 4% acetic acid‐VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2‐year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever‐screened and never‐screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health‐seeking behavior for gynecological and breast‐related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.

Determinants of Compliance in a Cluster Randomised Controlled Trial on Screening of Breast and Cervix Cancer in Mumbai, India

Objectives: This study aims to investigate the efficacy of screening by low-cost technology in down-staging and reducing mortality due to breast and cervix cancer. Methods: The present trial is a community-based, cluster randomised controlled cohort study on screening for breast and cervix cancers (clinical breast examination and visual inspection of the cervix after application of 4% acetic acid). Univariate and multivariate logistic regression analyses are conducted to identify the predictors of participation in screening. Results: The average compliance is 71.43 and 64.93% for breast and cervix cancer screening, respectively, with the highest compliance in round 1. At the end of 3 screening rounds, 94 and 84% of the eligible women were screened at least once for breast and cervix cancer, respectively. Younger women, women from other than Hindu and Muslim communities, school level-educated women, women belonging to lower-income families, Marathi-speaking women, married women and women who had previously consulted for any breast or gynaecological complaints had higher compliance to participation in screening. Conclusions: Good compliance rates to screening have been demonstrated in the trial, reflecting acceptance of the study by the society, which has implications while translating the trial into a programme.

Determinants of compliance in a cluster randomised controlled trial on screening of breast and cervix cancer in mumbai, India. 2. Compliance to referral and treatment.

Objectives: The study aims to investigate the efficacy of screening by low-cost technology in down-staging and reduction of mortality due to breast and cervix cancer. Methods: The present trial is a community-based, cluster randomised controlled cohort study on screening for breast and cervix cancers (clinical breast examination and visual inspection of the cervix after application of 4% acetic acid). Univariate and multivariate logistic regression analyses are conducted to identify the predictors of compliance to referral among screen-positive women and to treatment among cancer cases. Results: The compliance to diagnostic investigations is 73% among screen-positive women referred for breast cancer and 79% among women referred for cervix cancer. Younger women, women working in service or being self-employed, school level-educated women, mother tongue Marathi, participation in screening in all 3 rounds and women referred as screen positive for cervix cancer had higher compliance to diagnostic investigations. The compliance to treatment completion is higher in women diagnosed with breast cancer, at 95%, compared to 86% for cervix cancers and 81% for cervix pre-cancers. Conclusions: Good compliance rates along with a proper system of referral, further investigations, confirmation of diagnosis and treatment as demonstrated in this trial are crucial for successful screening programmes.

Ruptured degenerated uterine fibroid diagnosed by imaging.

BACKGROUND We report a ruptured uterine leiomyoma presenting as an acute abdomen. We document computed tomography and magnetic resonance imaging features of a ruptured uterine fibroid. CASE A woman with a large anterior wall uterine fibroid underwent a dilation and curettage for a threatened abortion. She had an uneventful recovery. Three weeks later, she presented with peritonitis. Computed tomography and magnetic resonance imaging optimally depicted the ruptured fibroid and excluded other causes of acute abdomen. Exploratory laparotomy and myomectomy confirmed the diagnosis. CONCLUSION This is a report of a ruptured degenerated fibroid causing acute abdomen outside of pregnancy. Computed tomography and magnetic resonance imaging aided in correctly establishing the diagnosis and optimizing the management of this patient.

Bilateral symmetrical adrenal hypermetabolism on FDG PET in paraneoplastic Cushing syndrome in breast carcinoma: correlation with contrast-enhanced computed tomography.

Paraneoplastic Cushing syndrome can be rarely a feature of breast carcinoma, with only 4 cases in the literature reported till date. We herein present a patient who underwent surgery for infiltrating ductal carcinoma of the right breast and was referred for FDG PET for disease evaluation. FDG PET study demonstrated significant bilateral symmetrical adrenal FDG uptake and multiple foci of uptake in the left cervical region and mediastinal nodes. Her serum adreno-corticotrophic hormone (ACTH) level was raised by 2 to 3 folds of the normal level (100 pg/mL). The uptake in the adrenal glands was inferred to be due to bilateral adrenal hyperplasia secondary to paraneoplastic Cushing syndrome that was substantiated by contrast-enhanced computed tomography and confirmatory biochemical examinations. The case is presented to stress upon the fact that “bilaterally symmetrical adrenal uptake” on FDG PET study in oncological setting should raise the suspicion of bilateral adrenal hyperplasia and should not be mistaken for adrenal metastasis.

Synchronous mucosa-associated lymphoid tissue (MALT) lymphomas involving bilateral orbits and breasts: a rare clinical entity

Primary orbital and primary breast lymphomas comprise very small subgroups of extranodal lymphomas. Clinical presentation at both these sites together is extremely rare. We describe a case of bilateral orbital and bilateral breast mucosa-associated lymphoid tissue (MALT) lymphomas with bilateral pre-auricular lymph nodal metastasis. The case history, staging and management for this unusual entity are discussed.

A Rare Demonstration of the Filarial Dance Sign in the Upper Limb Lymphatic Vessels Mimicking Deep Venous Thrombosis

Lymphatic filariasis is a clinical syndrome caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. The most common clinical form of the disease is hydrocele, with lymphedema and elephantiasis occurring less commonly.1 Various imaging modalities have been used for evaluation of filariasis. Among these modalities, sonography has become the most commonly used tool, not only for the diagnosis but also for assessment of the treatment response.2 We report a case of a patient receiving chemotherapy for ovarian carcinoma who presented with upper limb edema and pain, suspected to be deep venous thrombosis, in whom real-time sonography depicted the presence of the filarial dance sign in the upper limb lymphatic vessels. A 36-year-old woman presented to the outpatient department of the hospital with bilateral upper limb pain and swelling for the previous 2 months. On clinical examination, the upper limbs were swollen, and there were features suggestive of subacute onset of edema. With the suspicion of deep venous thrombosis, the patient was referred by the clinician to the ultrasound department. A detailed sonographic study of the upper limb was done to evaluate the patient’s condition. The sonographic examination, done with a high-frequency probe, revealed gross bilateral subcutaneous edema. The right axillary veins showed a normal caliber and color flow. However, sonography of the left upper limb showed the presence of a longitudinal thick-walled cystic lesion along the left axillary vessels. On careful observation, there was evidence of multiple hyperechoic signals with an undulating echo pattern within the lesion (Figure 1A and Video 1). On the basis of the B mode sonographic findings, we suspected a dilated lymphatic channel adjacent to the normal axillary vessels. Hence to characterize it further, color Doppler sonography was performed. Color Doppler sonography showed rapid movement of lymphatic fluids as irregular color signals in different parts of the lymphatic vessels, unlike the regular signals obtained from blood vessels (Figure 1B and Video 2). These imaging findings were consistent with the filarial dance sign of adult filarial worms in dilated lymphatic channels. In addition, the patient’s history revealed that she lived in a filarial endemic region, further corroborating our diagnosis. The patient was then treated with a course of diethylcarbamazine and showed substantial clinical improvement; however, posttreatment imaging was not available because the patient was lost to follow-up. Filariasis is a major health problem worldwide. According to the latest World Health Organization report,1 it is estimated that 120 million people in 81 countries are infected currently, and an estimated 1.34 billion live in areas where filariasis is endemic and are at risk of infection. Approximately 40 million people have the stigmatizing and disabling clinical manifestations of the disease.1 Among the affected countries, India alone contributes to around 40% of the global prevalence of the infection, and it is estimated that a minimum of

Unusual involvement of scalp and bilateral kidneys in an aggressive mediastinal diffuse large B cell lymphoma: documentation by FDG-PET imaging.

842 million is lost each year, secondary to treatment costs and work days lost from filariasis.3 The diagnosis of filariasis primarily depends on clinical signs and symptoms along with supportive laboratory tests and an appropriate epidemiologic background. Sonography has proved to be a noninvasive and cost-effective tool for diagnosis of filariasis.2 The presence of motile filarial worms on sonography as depicted by the filarial dance sign correlates with release of microfilariae into the lymphatic vessels and hence indicates an active infection.4 As the only diagnostic modality capable of showing the live adult filarial worms in vivo, sonography is very useful during the follow-up period to document the response of the worms to treatment.4 The filarial dance sign was first described by Amaral et al.5 They described the movements of live adult filarial worms in the lymphatic vessels as “peculiar, randomappearing movements of objects inside a vessel-like structure.”5 Sonography is used as a screening tool for detecting the presence of microfilariae in the scrotal lymphatic vessels in endemic regions. The presence of the filarial dance sign is a reliable indicator of live adult filarial worms.4 A review of the English literature revealed that the filarial dance sign has been described in the breast lymphatic vessels and less commonly in the lymphatic vessels of the uterus, of the groin, and between the muscular fibers of the thighs.6 The presence of microfilariae has also been previously reported in various unusual sites such as lymph nodes, breast lumps, thyroid glands, bone marrow, bronchial aspirates, nipple secretions, pleural and pericardial fluid, ovarian cyst fluid, and cervicovaginal smears and recently in the subcutaneous tissue of the head and neck.7–9 To our knowledge, the presence of the filarial dance sign in the dilated lymphatic vessels of the upper limb, which closely mimics deep vein thrombosis, has not been reported previously. Filariasis should be considered a primary differential diagnosis when evaluating a case of bilateral upper limb edema in endemic regions. On gray-scale and color

Imaging of the treated breast post breast conservation surgery/oncoplasty: Pictorial review

In the present communication, an unusual combination of scalp soft tissue and underlying brain involvement with intact skull bone coupled with bilateral renal involvement from a mediastinal diffuse large B cell lymphoma (DLBL) is presented. A 45-year-old man, a diagnosed case of mediastinal DLBL with bilateral lung involvement, was treated with conventional 6 cycles of chemotherapy and local external radiotherapy with initial good treatment response evidenced by considerable regression in mass size and regression in pulmonary lesions. Three months later, he returned with complaints of soft tissue swelling over the scalp; one of them in the high parietal bone and the other over the occipital region. A whole body FDG-PET at this time showed 2 moderate-sized foci in the scalp (with preservation of both tables of skull bone) and corresponding large foci in the brain parenchyma beneath, a superior mediastinal focus, a few foci in the apical and lower zone of left lung, extensive irregular uptake in the right pleura and the right lung parenchyma coupled with a loculated effusion in its lower zone and studded foci of hypermetabolism throughout the bilaterally enlarged kidneys. CT of the head confirmed the FDG-PET findings and histopathology of the biopsy from the scalp swelling was suggestive of DLBL. Ultrasound imaging of the abdomen showed lobulated bilaterally enlarged kidneys with multiple hypoechoic areas within them. The patient underwent palliative local external radiotherapy to the brain and systemic chemotherapy with poor clinical results with raised serum beta-2 microglobulin and serum LDH levels and deranged renal function. The patient died within a month after the FDG-PET study. The event of scalp and bilateral renal involvement from DLBL is rare in lymphoma literature and this report highlights that such unusual events can occur as part of widespread dissemination and underscores the importance of whole-body imaging with FDG-PET.

Postoperative deep vein thrombosis in patients with colorectal cancer.

Mammographic appearance of the normal breast is altered in the post-operative setting. It is essential to be aware of the normal findings as well as to identify features of recurrent disease with particular emphasis on radiological-pathological concordance. Digital breast tomosynthesis and volumetric breast density add incremental value in this clinical setting. We present a pictorial review of various cases to illustrate normal post-operative findings as well as mammographic features suspicious for recurrent disease.