Effect of preoperative short course famotidine on TILs and survival in breast cancer.

BACKGROUND: Histamine receptor antagonists have been shown to induce tumor-infiltrating lymphocytes (TILs) in colonic cancers and improve survival. The role of histamine receptor anatagonists in breast cancer is unclarified. AIM: To evaluate the role of histamine receptor antagonists in inducing (TILs) in breast cancer. METHOD: Forty-five patients with operable breast cancers (25 cases who received preoperative famotidine and 20 controls) were studied for the effect of famotidine in inducing TILs and survival in breast cancer. RESULTS: Significant TILs were seen in 75% (18/24) of cases as opposed to 35% (7/20) controls. In logistic regression analysis the only variable found to be predictive of TILs was famotidine, odds ratio 7.324 (1.693-31.686) P=0.008. In Cox's regression presence of TILs was favorably associated with improved disease free survival at a median follow up of 35.56 months. The hazard ratio for disease relapse was 3.327 (1.174-9.426) P=0.024 in TIL negative as compared to TIL positive patients. Famotidine use alone was not significant in the original model, however, on incorporation of quadrant of involvement in addition to other established prognostic factors in the above multivariate model, it assumed borderline significance with a hazard ratio for disease free survival 3.404 (1.005-11.531, P=0.049). CONCLUSIONS: Preoperative short course famotidine induces TILs in breast cancer. Patients with TILs demonstrable in tumor specimens had an improved disease free survival. Famotidine may improve disease free survival in breast cancer and these findings need validation in larger population subsets.

Non small cell lung cancer (NSCLC): current status and future prospects.

The incidence of lung cancer is rising dramatically and it is now the commonest cause of mortality and morbidity not only in the industrialised countries, but in developing nations like India as well. Tobacco smoking has consistently been demonstrated to be an important aetiological factor, though lung cancer occurs in non-smokers also. In spite of great advances in radiological and molecular diagnostic techniques, the ideal screening marker for early detection of lung cancer has still not been found. Histological diagnosis and staging is essential for selecting the mode of therapy in patients with lung cancer. Stages I and II are amenable to surgery. However, advanced stage III and IV need an individualised combination of surgery, chemotherapy and radiotherapy. With a better understanding of the cellular mechanisms operating in carcinogenesis, newer target specific modalities are being developed and tested in order to stem this disease, which threatens to assume epidemic proportions.

Laparoscopic Nissen fundoplication; results of a prospective pilot study.

Laparoscopic fundoplication is rapidly becoming the surgical procedure of choice in western countries for the management of gastro-oesophageal reflux disease (GERD). Experience with this technique is limited in India. Most operations continue to be performed through the traditional open technique, thus denying the advantage of a minimal invasive approach to patients. This study was done to evaluate the feasibility and short term results of laparoscopic Nissen fundoplication. Between June 2000 and March 2002, a total of 10 patients with GERD refractory to medical therapy or requiring daily treatment underwent laparoscopic Nissen fundoplication. Preoperative evaluation included scoring of symptoms, oesophagogastroduodenoscopy, barium swallow and nuclear scan. The intraoperative and post-operative course of the patients was recorded. At 3 months post-surgery, patients were re-evaluated using pre-operative symptom scores and investigations to assess the benefit of and complications associated with surgery. Laparoscopic nissen fundoplication was successfully completed in all the patients. Follow up ranged from 3 to 18 months with a mean of 5.9 months. The mean symptom score decreased from 10.1 pre-operatively to 1.7 (p value < 0.001). Eight out of 9 patients (88%) had endoscopic resolution of oesophagitis. Seven patients (70%) were off medication following surgery while the remaining 3 (30%) were taking medication intermittently. Overall, 80% of the patients were satisfied with the surgery. One patient required re-exploration due to bleeding from a short gastric vessel. The most frequent post-operative complication was temporary dysphagia in 60% of patients, which improved with conservative management over 2 to 3 weeks. We concluded that laparoscopic Nissen fundoplication is a safe and effective procedure to treat patients with GERD.

Spontaneous rupture of spleen in viral hepatitis A.

A twenty-five year old man presented with history of fever, malaise and jaundice and developed a spontaneous rupture of the spleen during hospital admission. Investigations revealed deranged liver function tests and positive serology for hepatitis A.

Role of hepatobiliary scintigraphy in management of postoperative bile leak into the lesser sac.

A case with bile leak into the lesser sac of peritoneum is reported. Although bile leak following biliary surgery or trauma is not uncommon, isolated bile leak into the lesser sac is rare. This information may be vital for appropriate placement of the drainage tube in the abdomen. A hepatobiliary study, as reflected in this report, is extremely useful in guiding the surgeon in this respect.

Cyclical mastalgia--is it a manifestation of aberration in lipid metabolism?

Several therapeutic and investigative studies suggest the possibility of the role of lipid profile aberrations in the pathophysiology of cyclical mastalgia. This prospective study is aimed to look for such aberrations. Fifty-seven patients of benign breast disease were included in this study who were symptomatic for at least 6 months prior to presentation. Detailed serum lipid profile work up was performed on day 1, 15 and 25 of menstrual cycle. The patients with symptoms of maximal severity (or limited to) during leuteal phase of menstrual cycle were included in group I (n = 32). Those who had mastalgia, but did not have above mentioned cyclical variation, were included in group II (n = 25). Since noncyclical mastalgia is a group of heterogeneous disorders of varied etiology, the patients in group II were treated as controls. At day 25, there was an elevation in mean values of HDL-C (P = 0.03) and HDL-C/LDL-C ratio (P = 0.01), and reduction in TC/HDL-C ratio (P < 0.03), in group I. This has not been the case with group II patients. When the patients of mastalgia were treated with low fat dietary regimen, there was a significant difference in the responses of these two groups (P value < 0.0001). Based on the results of lipid profile study and dietary intervention, we conclude that cyclical mastalgia is an entity which is distinctly different from noncyclical mastalgia and needs a different therapeutic approach. Our data, both investigative and therapeutic, suggests that cyclical mastalgia may be a result of cyclical aberrations in lipid metabolism, and the physiological treatment in the form of an appropriate dietary regimen holds a considerable promise.

Current practice in biliary surgery: the Indian scenario.

OBJECTIVE: Documentation of current biliary surgical practices of surgeons in India. METHODS: A postal questionnaire survey of the consultants in surgery in all the medical colleges in India was done to establish their current practice regarding cholecystectomy and to assess the influence of recent studies on their practice. RESULTS: The response rate was 23% (264/1127). About half of the surgeons did both ultrasonography and oral cholecystography for the diagnosis of cholelithiasis. Acute cholecystitis was managed conservatively by 80% of surgeons. Antibiotics were used by all surgeons but 87% of them used antibiotics for more than one day. Peroperative cholangiography was done in all cases by 20% of those who had the facilities available. Incidental appendectomy was done by 26% of surgeons. Drain was used in all cases by 78% of surgeons. Patients were discharged after suture removal by 77% of surgeons. CONCLUSIONS: The practices of the Indian surgeon surveyed were against the recommendations in current literature which did not seem to have had much impact on them regarding their practice of biliary surgery.

Efficacy of low fat diet in the treatment of benign breast disease.

BACKGROUND. Previous studies have shown that lipid abnormalities have a role in the pathogenesis of benign breast disease. However, few investigators have tried to reduce dietary fat to treat this disorder. METHODS. Between 1990 and 1993, we conducted a prospective cohort study to find out the efficacy of a low fat diet (less than 15% fat-derived calories) in the treatment of benign breast disease in patients who had been symptomatic for 6 months or more. The study was conducted in two phases. In the first phase 36 patients were alternately assigned to control and treatment groups for 6 months and in the second phase 121 patients (including all those in phase I) were given treatment (median follow up 25 months, range 3 to 39 months). Detailed lipid profiles were studied at the time of presentation and at 4 and 5 months. RESULTS. Phase I results showed that after 6 months none of the patients in the control group had experienced any alteration in their symptoms and signs but in the treatment group 12 out of 17 improved. In phase II improvement in pain (68 out of 97; 70%), nodularity (51 out of 79; 64%) and discharge (15 out of 19; 80%) was seen. There was a significant decline in the mean values of total cholesterol and high-density lipoproteins at the end of 5 months of treatment. CONCLUSION. A low fat diet improves the symptoms as well as the lipid profile in patients with benign breast disease.

Malignant insulinoma presenting with recurrent episodic loss of consciousness.

A 57 year old male presented with episodic behavioural abnormalities and loss of consciousness for 2 years. His fasting blood glucose was 20 mg/dl and corresponding insulin level 119 uU/ml. His EEG showed intermittent rhythmic delta activity. Abdominal CT scan revealed an enhancing mass in the tail of the pancreas and secondaries in the liver. After distal pancreatectomy, resection of the left lobe of the liver and chemotherapy, the hypoglycaemic spells subsided. Histopathology revealed an islet cell tumour with metastases in the liver. Episodic neurobehavioural dysfunction should alert towards the possibility of hypoglycaemia.

Fine needle aspiration cytology as a preliminary diagnostic procedure for asymptomatic cervical lymphadenopathy.

Fine needle aspiration cytology (FNAC) was used as a preliminary diagnostic procedure in evaluating discrete, asymptomatic cervical lymphadenopathy of more than four weeks duration. Benign pathologies were encountered in 294/359 patients (82%); of these 86% had tuberculosis. Even in the elderly, a large number of patients (25/78) harboured tubercular lymph glands. FNAC obtained adequate material for cytologic diagnosis in 97.5% and had an overall accuracy rate of 97%. Malignancy was correctly diagnosed in 100%; in tuberculosis the accuracy rate of 96% with a 3.5% false negative results. FNAC is reliable as the initial evaluating procedure even in benign disorders; it is also cheap, speedy and easy to perform, with no complications, making it suitable for wider application in developing countries with scant resources.

Thyroid carcinoma.

Eleven cases of thyroid cancer occurring in patients below 15 years of age are presented. The youngest patient was 4 years old. There were 4 boys and 7 girls in the study group. None of the patients had received head and neck irradiation. All patients had well differentiated cancers; there were 4 follicular carcinomas and 3 of these occurred in patients below 10 years of age. Six patients presented with solitary thyroid nodules. Lymph node involvement had occurred in 63.7% of cases. One patient presented with CNS metastasis. Treatment aimed at near total thyroidectomy was performed in 9 patients. Two patients died of the disease during the follow up period and another 3 patients are alive. Postoperatively radioactive iodine was routinely used for evaluating and treating residual and recurrent disease.