Complex chest wall reconstruction after excision of malignant phyllodes tumour.

Phyllodes tumour is a rare breast tumour which is locally invasive, and full thickness chest wall involvement by phyllodes is rarely reported. A woman presented with recurrent phyllodes tumour and multilobulated exophytic mass of size 18.5×5.3 cm in anterior chest wall which was abutting the right 2nd-7th rib, left 3rd-5th rib and costal cartilages. She underwent wide excision of the left chest wall tumour with excision of left 3rd-5th rib, with polypropylene mesh and pedicled lattismus dorsi myocutaneous flap reconstruction. After recovery, 3 weeks later, she underwent wide excision of the phyllodes tumour on the right chest wall with excision of 2nd-7th rib, lateral border of sternum, right crus of the diaphragm and the lower lobe of the right lung. Anterior chest wall was reconstructed using scaffold made from Steinmann pins and polypropylene mesh with greater omentum pedicled flap and split thickness skin graft.

iTRAQ proteomics of sentinel lymph nodes for identification of extracellular matrix proteins to flag metastasis in early breast cancer.

Patients with early breast cancer are affected by metastasis to axillary lymph nodes. Metastasis to these nodes is crucial for staging and quality of surgery. Sentinel Lymph Node Biopsy that is currently used to assess lymph node metastasis is not effective. This necessitates identification of biomarkers that can flag metastasis. Early stage breast cancer patients were recruited. Surgical resection of breast was followed by identification of sentinel lymph nodes. Fresh frozen section biopsy was used to assign metastatic and non-metastatic sentinel lymph nodes. Discovery phase included iTRAQ proteomics coupled with mass spectrometric analysis to identify differentially expressed proteins. Data is available via ProteomeXchange with identifier PXD027668. Validation was done by bioinformatic analysis and ELISA. There were 2398 unique protein groups and 109 differentially expressed proteins comparing metastatic and non-metastatic lymph nodes. Forty nine proteins were up-regulated, and sixty proteins that were down regulated in metastatic group. Bioinformatic analysis showed ECM-receptor interaction pathways to be implicated in lymph node metastasis. ELISA confirmed up-regulation of ECM proteins in metastatic lymph nodes. ECM proteins have requisite parameters to be developed as a diagnostic tool to assess status of sentinel lymph nodes to guide surgical intervention in early breast cancer.

Comparison of Wire-Guided Lumpectomy (WGL) Versus Hematoma-Directed Ultrasound-Guided Lumpectomy (HDUGL) in Management of Nonpalpable Breast Lesions in Achieving a Negative Resection Margin: a Randomized Trial with Superiority Hypothesis and Cost-effectiveness Analysis.

The advances in imaging techniques and growing awareness have increased the detection of nonpalpable breast lesions, which may be neoplastic or high-risk lesions. The standard technique of localizing these nonpalpable breast lesions is wire-guided biopsy/lumpectomy. However, wire-guided excision is fraught with the complications of migration, transection, patient discomfort, pneumothorax, vasovagal episodes, and injury to the radiologist, surgeon, and pathologist. We embarked upon a randomized controlled trial to compare the cost-effectiveness and patient-reported outcome (PRO) with hematoma-directed ultrasound-guided lumpectomy (HDUGL) versus conventional wire-guided lumpectomy (WGL) for nonpalpable breast lesions. This study was a parallel design, randomized controlled trial with a superiority hypothesis. Twenty-five patients could be randomized to wire-guided lumpectomy (WGL) group (n = 13) and hematoma-directed ultrasound-guided lumpectomy (HDUGL) group (n = 12). Post-excision specimen sonography and mammography for assessing adequacy of margin were done. A margin shave was performed in cases of close or suspicious margin on ultrasonography or mammogram. Both the groups were comparable in age, tumor size, histological subtypes, and location of lesions. The median resection volume in two groups was 34.5 (26.5) ml for HDUGL vs. 41 (15) ml for WGL. Intraoperative cavity shave was required only in the WGL group (n = 3.23%) and margin positivity was also more in the WGL group (n = 2,15.38%) as compared to the HDUGL group (n = 1,8.33%) but neither differences in cavity shave nor positive margins leading to re-operations were statistically significant. The difference in cost of surgery in two groups (INR 4680 ± 560.00 for HDUGL and INR 7486 ± 616.41 for WGL) was statistically significant (P = 0.00). Resultantly, HDUGL was more cost-effective (INR 5105.45) than WGL (INR 8847.09). Patients in the HDUGL group were more satisfied according to the Likert scale of 5 but this difference in two groups was not statistically significant (P = 0.07). The hematoma-directed ultrasound-guided lumpectomy (HDUGL) is better than wire-guided lumpectomy (WGL) for nonpalpable breast lesions in terms of cost-effectiveness. Trial details: CTRI No. CTRI/2019/05/019347. Registered on 24/05/2019, Registered prospectively.

Proteomics of Sentinel Lymph Nodes in Early Breast Cancer for Identification of Thymidylate Synthase as a Potential Biomarker to Flag Metastasis: A Preliminary Study.

INTRODUCTION: Breast cancer is the second most common cancer in women across the world. Some of the patients who present in the early stage of disease are affected by metastasis to the axillary group of lymph nodes. The first among this group that is affected is called as sentinel lymph node, and its diagnosis is crucial for the staging of cancer thereby dictating the type of surgical therapy. Therefore, the sentinel lymph node status provides the most relevant information to the surgeon and patient prognosis. The expanded utilization of breast conservation surgery has declined the morbidity associated with mastectomy and axillary lymph node surgery. Recent interest is, therefore, centered on techniques that allow accurate assessment of the sentinel lymph node metastasis. A current procedure such as sentinel lymph node biopsy (SLNB) that is used to assess axillary lymph node metastasis is neither specific nor sensitive, and besides, it is time-consuming. OBJECTIVE: To compare the protein profiles between metastatic and non-metastatic lymph nodes to identify a biomarker that can flag lymph node metastasis. MATERIALS AND METHODS: Women with early breast cancer were screened using mammography imaging and recruited to the study. Surgical resection was done to remove the breast tissue, and sentinel lymph node was identified using fluorescein and methylene blue tracer. Lymph node was sliced, and one set was sent for histopathology, which was considered the gold standard to assess the metastatic status of the lymph node. One set of slices was taken for proteomic experiments. Proteins were labelled with fluorescent cyanine tags and were subjected to difference gel electrophoresis experiment. Differentially expressed spots that had at least a twofold relative ratio and consistent pattern across three sets of biological replicate experiments were marked. Gel spots were trypsin digested and identified on mass spectrometry machine. Validation study was done by Western blot experiment on the same set of samples. RESULTS: Thymidylate synthase has a twofold higher expression in the metastatic sentinel lymph nodes as compared to non-metastatic lymph nodes in early breast cancer patients. CONCLUSION: Differential in gel expression proteomics is an ideal platform for the identification of potential protein biomarker candidates that can differentiate metastatic from non-metastatic lymph nodes in early breast cancer. The identification of thymidylate synthase offers a scope to develop an on-table diagnostic kit to assess the status of sentinel lymph nodes during mastectomy procedure to guide surgical management of axillary lymph nodes in early breast cancer.