Sunil Chumber

Gallium-68-DOTA-NOC PET/CT of Patients With Gastroenteropancreatic Neuroendocrine Tumors: A Prospective Single-Center Study

OBJECTIVE The objective of this study was to evaluate the role of (68)Ga-labeled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI(3)-octreotide (DOTA-NOC) PET/CT in the diagnosis and management of gastroenteropancreatic neuroendocrine tumors (NETs). SUBJECTS AND METHODS One hundred nine patients (median age, 50 years) with gastroenteropancreatic NETs underwent (68)Ga-DOTA-NOC PET/CT. PET/CT was performed after injection of 132-222 MBq (4-6 mCi) of (68)Ga-DOTA-NOC. Images were evaluated by two experienced nuclear medicine physicians both qualitatively as well as quantitatively (maximum standardized uptake value [SUV(max)]). Results of PET/CT were compared with the results of conventional imaging. Histopathology results, when available, and follow-up PET/CT or conventional imaging with biochemical markers were considered to be the reference standards. RESULTS Gallium-68-DOTA-NOC PET/CT showed sensitivity and specificity of 78.3% and 92.5%, respectively, for primary tumor and 97.4% and 100% for metastases. It was better than a conventional imaging modality for the detection of both primary tumor (p < 0.001) and metastases (p < 0.0001). It changed the management strategy in 21 patients (19%) and supported management decisions in 32 patients (29%). CONCLUSION Gallium-68-DOTA-NOC PET/CT appears to be a highly sensitive and specific modality for the detection of gastroenteropancreatic NET. It is better than conventional imaging for the evaluation of gastroenteropancreatic NETs and can have a significant impact on patient management.

Meta-analysis of Randomized Controlled Trials on Hydrocolloid Occlusive Dressing Versus Conventional Gauze Dressing in the Healing of Chronic Wounds

Chronic wound management is a difficult area in surgical practice. A wide range of dressings have been recommended for the management of chronic wounds. The present meta-analysis was undertaken to determine the effectiveness of hydrocolloid dressing (HCD) in the healing of chronic wounds compared with conventional gauze dressing. All available controlled clinical trials published before December 2001 that compared HCD to conventional gauze dressing in the healing of chronic wounds were systematically reviewed. We identified and analysed 12 randomized trials (11 published; 1 unpublished) comprising 693 patients with 819 ulcers. The overall odds ratio under the fixed effect model was 1.72, that is, 72% more ulcers healed completely with HCD than with conventional gauze dressing. This result was both clinically and statistically significant.

Comparison of Interrupted Versus Continuous Closure in Abdominal Wound Repair: A Meta-analysis of 23 Trials

OBJECTIVE There is a lack of consensus among surgeons over interrupted versus continuous methods of abdominal wound closure. The objective of this study was to perform a meta-analysis to estimate the pooled odds ratio (OR) for dehiscence and incisional hernia in the interrupted technique of laparotomy wound closure as compared to the continuous technique. METHODS All randomized, controlled trials comparing continuous and interrupted methods of laparotomy wound closure, with burst abdomen and/or incisional hernia as the outcomes, were included in the meta-analysis. MEDLINE, Clinical Evidence and the Cochrane Library were searched. Burst abdomen and incisional hernia were the two primary outcomes. RESULTS Twenty-three studies were identified, with a total of 10,900 patients. The interrupted method of closure was associated with significantly less dehiscence as compared with the continuous method (OR, 0.576; p = 0.014; relative risk reduction, 39.8%; number needed to treat, 143). The interrupted technique was also found to be better in the nonabsorbable suture, vertical incision and mass closure subgroups. However, no difference in the hernia risk was found between the two methods. CONCLUSION Interrupted laparotomy wound closure reduces the odds of dehiscence by half compared with continuous wound closure.

Postpartum acquired haemophilia: clinical recognition and management

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32‐year‐old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laprotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA® therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Blunt abdominal trauma with delayed rupture of splenic haematoma in a haemophiliac patient

A 13‐year‐old haemophilia A patient presented with pain in the abdomen, 4 days after a blunt abdominal trauma. The computed tomography scan of the abdomen showed a large splenic haematoma. The patient was initially managed with factor VIII replacement therapy, but 4 weeks later he had a delayed rupture of the splenic haematoma with haemoperitoneum and shock. An elective splenectomy under factor VIII therapy was successfully performed.

Anaplastic transformation of metastatic papillary thyroid carcinoma at shoulder mimicking soft tissue sarcoma

A 52-year-old woman presented with fracture upper end of the left humerus after trivial trauma and aspiration cytology from the lytic lesion in the upper humerus seen on X-ray revealed a metastatic papillary carcinoma from the thyroid. Total thyroidectomy confirmed the papillary carcinoma thyroid. Post-operatively, she was given radioactive iodine (I-131) ablation therapy for 8 years and was asymptomatic during this period; however, for the last 1 year, she has been complaining of swelling in the shoulder, which did not respond to palliative radiotherapy and rapidly increased in size. Disarticulation of the shoulder joint was performed, which showed anaplastic carcinoma on histopathological examination. Anaplastic transformation of papillary carcinoma at the metastatic sites is well documented in the literature and is rare. However, the same has not been reported at the shoulder and from India before. Although soft tissue sarcomas are most common at this site, however, the possibility of anaplastic transformation should be kept in the differential diagnosis of rapidly enlarging painful mass in a known case of metastatic thyroid carcinoma to prevent misdiagnosis.

Control of presacral venous bleeding, using thumbtacks

BackgroundMassive life threatening bleeding from presacral venous plexus in gynecological surgery, though uncommon can be fatal when conventional methods fail.CaseIn the present case, a 55-year-old woman undergoing radical hysterectomy for cancer cervix was saved using thumbtacks to control bleeding from presacral vessels when conventional methods were ineffective.ConclusionUse of thumbtacks in such patients is simple, cost effective and life saving.

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.

Comparison of 18F-Fluorocholine positron emission tomography/computed tomography and four-dimensional computed tomography in the preoperative localization of parathyroid adenomas-initial results

Objective: We aimed to compare the diagnostic accuracy of 18F-Fluorocholine (FCH)-positron emission tomography/computed tomography (PET/CT) and four-dimensional (4D)- CT in detection and localization of eutopic and ectopic parathyroid adenoma (PA) in patients with hyperparathyroidism. Materials and Methods: Five patients with primary hyperparathyroidism underwent FCH-PET/CT after 60 min of 185 MBq of intravenous 18F-FCH administration. Images were acquired from head to mediastinum at 3 min per bed position. No intravenous contrast was used. All patients underwent 4D-CT within 2 weeks of the FCH-PET/CT, with a precontrast, post contrast arterial, and venous phase with 75 ml intravenous Iohexol 350 followed by 25 ml saline chase. Histopathology was considered as the gold standard. Results: Both modalities showed 100% concordance in the detection of parathyroid lesions. Both FCH-PET/CT and 4D-CT detected 7 lesions in 5 patients, with 4 patients having a single lesion, and 1 patient having three lesions. Of the 7 reported lesions, 4 were eutopic and 3 were ectopic. No additional lesions were detected by either modality in comparison to the other. All 7 specimens were resected and histopathology showed PA/hyperplasia. Conclusion: FCH-PET/CT and 4D-CT are equally efficacious in detection and localization of eutopic and ectopic PA. This may open up the possibility of using FCH-PET/CT in patients with negative conventional imaging who cannot undergo contrast studies.

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.