Phyllodes Tumors of the Breast-Experience in a Tertiary Care Center.

Phyllodes tumors (PTs) are rare neoplasms of the breast that are a challenge in clinical practice. Though mostly benign, they are notorious for local recurrence, requiring adjuvant treatments. This study was planned to report the clinicopathological features and outcomes of patients with PT treated at our center. Details of all patients who underwent surgery for PT in the last 6 years (December 2017-December 2023) were obtained from our prospectively maintained database. The demographic, clinical, radiological, pathological, and follow-up details were recorded and analyzed. Statistical analyses were carried out with Jamovi version 2.3.18. Out of 61 suspected PTs by triple assessment, 9 were excluded due to a non-phyllodes diagnosis on histopathology. We included 52 women with a mean age of 38.2 ± 11.0 years, most of whom were premenopausal (57.7%). BI-RADS 4 was the most common finding on radiological assessment (65.4%). Core needle biopsy (CNB) was the most frequently employed modality for histological diagnosis preoperatively (65.4% of cases). Wide local excisions (WLE) and mastectomies were done in 63.5% and 36.5% of patients, respectively. Benign, borderline, and malignant phyllodes constituted 67.3%, 15.4%, and 17.3% of tumors, respectively. Patients undergoing breast conservation surgery (BCS) had a significantly smaller mean tumor diameter than those who underwent a mastectomy (p < 0.001). Overall, the margin positivity rate was 34.6%. Patients undergoing mastectomy developed more local recurrence compared to WLE, although the difference was not significant (p = 0.400). The outcome following surgical excisions of large PTs in terms of margin positivity and local recurrence is the same, irrespective of whether BCS or mastectomy is done. A negative pathological margin width of > 1 mm appears acceptable. Malignant phyllodes with positive margins are associated with a higher rate of recurrence but positive margins in patients with other subtypes may not translate into recurrence, at least in the short term.

Sentinel lymph node biopsy in early breast carcinoma using fluorescein sodium and methylene blue dye: A validation study.

The availability of radioisotopes for sentinel lymph node biopsy (SLNB) in breast carcinoma is limited in low- and middle-income countries and thus the need for other reliable tracers exists. We aimed to validate the effectiveness of fluorescein sodium (FS) together with methylene blue dye (MBD) for patients with node-negative early breast carcinoma in a prospective cross-sectional study. Patients underwent SLNB using FS and MBD followed by axillary dissection to validate results. Sentinel lymph node (SLN) identification rate and false negative rate were assessed for all three tracers/combinations (MBD, FS, and MBD + FS). We concluded that SLNB using a combination of FS and MBD has an acceptable rate of SLN identification but the addition of FS provided no additional benefit.

A systematic review and meta-analysis of diagnostic performance of fluorescein-guided sentinel lymph node biopsy in early breast cancer.

BACKGROUND: Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer. OBJECTIVES: The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy. METHODS: Eligibility criteria: Studies where SLNB was performed using FS. INFORMATION SOURCES: PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool. SYNTHESIS OF RESULTS: The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model. RESULTS: A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07). CONCLUSION: Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial.

BACKGROUND: Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo. PATIENT AND METHODS: Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared. RESULTS: The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar. CONCLUSIONS: Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.

Automated cardiac arrhythmia detection techniques: a comprehensive review for prospective approach.

Abnormal cardiac functionality produces irregular heart rhythms which are commonly known as arrhythmias. In some conditions, arrhythmias are treated as very dangerous which may lead to sudden cardiac arrest. The incidence and prevalence of cardiac anomalies seeks early detection of arrhythmias using automated classification techniques. In the past, numerous automated arrhythmia detection techniques have been developed that are based on electrocardiogram (ECG) signal analysis. Focusing on the prospective research in this field, this article reports a comprehensive review of existing techniques that are obtained using search engines such as IEEE explore, Google scholar and science direct. Based on the review, the existing techniques are broadly categorized into two types: machine-learning and deep-learning-based techniques. In this study, it is noticed that the performance of the machine-learning-based arrhythmia detection techniques depend on pre-processing of ECG signal, R-peaks detection, features extraction and classification tools while the deep-learning-based techniques do not require the features extraction step. Generally, the existing techniques utilize Massachusetts Institute of Technology-Beth Israel Hospital arrhythmia database to evaluate the classification performance. The classification performance of automated techniques also depends on ECG data used for training and testing of the classifier. It is expected that the performance should be evaluated using a variety of ECG signals including the cases of inter-patient and intra-patient paradigm. The existing techniques also require to deal with the class-imbalance problem. In addition to this, a specific partition-ratio between training and testing datasets should be maintained for fair comparison of performance of different techniques.

A Glove-Based Virtual Hand Rehabilitation System for Patients With Post-Traumatic Hand Injuries.

Recent studies have shown that virtual gamified therapy can be a potential adjunct to conventional orthopedic rehabilitation. However, the off-the-shelf gaming consoles used for virtual rehabilitation pose several practical challenges in deploying them in clinical settings. In this article, we present the design of a portable glove-based virtual hand rehabilitation system (RehabRelive Glove) that can be used at both clinics and homes for physiotherapy. We also evaluate the system's efficacy on patients with post-traumatic hand injuries. Thirty patients were randomly categorized into groups A (virtual rehabilitation) and B (conventional physiotherapy). Both groups received fifteen 25-minute sessions of respective therapy over three weeks. The wrist and finger joints' range of motion (ROM) and grip strength were measured every seven sessions to compare the efficacy. Group A showed about 1.5 times greater improvement in flexion/extension ROM of the wrist compared to Group B. While both groups improved finger ROM and grip strength with time, no significant difference was observed between the groups. The results suggest that the proposed virtual rehabilitation system effectively enables patients with hand injuries to recover ROM faster.

Breast carcinoma presenting with upper limb lymphedema - A rare case.

Lymphedema (LE) in a breast cancer patient usually results from axillary lymph node dissection, sentinel lymph node biopsy, and/or axillary radiotherapy. Although lymphatic obstruction and consequent LE can occur due to axillary lymph node involvement, such presentation in breast cancer patients has rarely been reported. This report describes the case of a 50-year-old lady with right breast carcinoma who presented with right upper limb lymphedema. Surprisingly, she did not have any bulky axillary lymphadenopathy that could have accounted for lymphedema of the upper limb, but a suspicious breast mass was present on clinical examination. Diagnosis of breast cancer on clinical examination can be challenging in such patients due to breast edema and careful imaging of the breast and axilla with appropriate imaging tools (mammogram, ultrasound, MRI, PET mammography) should be resorted to before excluding malignancy. Lymphoscintigraphy confirmed the findings of lymphedema in the right upper limb and revealed uptake in the epitrochlear lymph nodes of the contralateral limb suggesting that she might had pre-existing widespread "subclinical lymphedema" which presented as "clinical lymphedema" in right upper limb after axillary lymph node/lymphatic involvement by right breast carcinoma.

Soft Tissue and Lower Limb Muscle Metastases from Breast Carcinoma: An Unreported Entity.

Soft tissue metastasis from carcinoma breast is rare, and still rarer is metastasis to skeletal muscles. So far, soft tissue metastasis from breast carcinoma has been reported only in a small number of case series and case reports. To the best of our knowledge, no case of breast cancer metastasizing to the lower limb muscles has been reported. It is important to differentiate soft tissue metastasis from primary soft tissue malignancy, as the management and prognosis of these differ markedly. Here, we present a case of breast cancer metastasizing to the soft tissue at multiple sites including the right thigh muscles.

The Mizoroki-Heck reaction between in situ generated alkenes and aryl halides: cross-coupling route to substituted olefins.

This review covers palladium-catalyzed typical Mizoroki-Heck cross-coupling reactions of aryl halides with in situ generated alkenes, by following a typical Heck coupling mechanism to form substituted olefins unlike direct cross-coupling of alkenes with aryl halides in Heck olefination. These reactions solve the issue of alkenes undergoing polymerization at high temperatures and increase reaction efficiency by reducing the reaction time and purification steps.

Indian surgery Trainee's perspective on surgical ergonomics principles and education: A long road ahead.

INTRODUCTION: This study aimed to determine the baseline knowledge and beliefs, along with the impact of incorporating surgical ergonomics lectures during a residency. METHODS: A cohort of 123 Indian surgical residents participated in this educational intervention, which consisted of two educational webinars on ergonomics. Both pre- and post-intervention surveys were electronically sent to the participants. These included questions related to their demographics, prevalence of musculoskeletal (MSK) symptoms, and factors affecting participant awareness of ergonomic recommendations. RESULTS: Seventy-one residents responded to the pre-webinar survey. Eighty-five percent of respondents reported MSK symptoms, with the most common being pain (70%) and stiffness (40%), which the residents attributed to their surgical training. Forty-six residents completed the post-webinar survey. The majority of respondents strongly agreed or agreed that surgical ergonomic educational sessions improved their understanding of the fundamental causes of MSK symptoms and increased their awareness of options available for prevention MSK injuries. CONCLUSION: The rate of MSK symptoms and/or injury was high among this cohort of surgical residents. These surveys and educational session demonstrated there is limited awareness of the comprehension of ergonomics related to surgical procedures. Our study shows that a simple surgical ergonomic educational intervention can lead to improved understanding of prevention and ergonomic changes.

Total vs less than total thyroidectomy for benign multinodular non-toxic goiter: an updated systematic review and meta-analysis.

BACKGROUND: We have performed an updated meta-analysis of randomized controlled trials (RCT) comparing total thyroidectomy (TT) with less than total thyroidectomy (LTT) for benign multinodular non-toxic goiter (BMNG). OBJECTIVES: The objective was to evaluate the effects and outcomes of TT as compared to LTT. METHODS: Eligibility criteria: RCTs comparing TT vs LTT. INFORMATION SOURCES: PubMed, Embase, Cochrane Library and online registers were searched for articles comparing TT with LTT. Risk of bias: Articles were assessed for risk of bias using the Cochrane's revised tool to assess risk of bias in randomized trials (RoB 2 tool). SYNTHESIS OF RESULTS: The main summary measures were risk difference using a random effects model. RESULTS: Five randomized controlled trials were included in the meta-analysis. Recurrence rate was lower for TT compared to LTT. Adverse events like temporary or permanent recurrent laryngeal nerve (RLN) palsy and permanent hypoparathyroidism were similar in both groups except for the rate of temporary hypoparathyroidism which was lower in the LTT group. DISCUSSION: All studies had unclear risk of bias for blinding of the participants and personnel and high risk of bias for certain selective reporting. This meta-analysis did not show any clear benefit or harm of either procedure (TT vs LTT) for goiter recurrence and re-operation rates (for both recurrence and incidental thyroid cancer). However, re-operation for goiter recurrence was significantly higher in the LTT group based on a single RCT. Evidence suggests increased rates of temporary hypoparathyroidism with TT but there was no difference in the rate of RLN palsy and permanent hypoparathyroidism between the two methods. The overall quality of evidence was low to moderate.

Pathway to achieve a sustainable food and land-use transition in India.

India has committed to reducing the emissions intensity of GDP by 33-35% from the 2005 level by 2030 in alignment with objectives of the Paris Agreement. This will require a significant reduction in greenhouse gas (GHG) emissions from the food and land-use sector. In this paper, we construct three potential pathways for India to achieve its emissions target by 2050 involving moderate ambitions of mitigation action (BAU), moderate ambitions combined with achieving healthy diets (BAU + NIN), and high levels of mitigation action inclusive of healthy diets (SUSTAINABLE). Using an integrated accounting tool, the FABLE Calculator, that harmonizes various socioeconomic and biophysical data, we project these pathways under the conditions of cross-country balanced trade flows. Results from the projections show that the demand for cereals will increase by 2050, leading to increased GHG emissions under BAU. Under the SUSTAINABLE pathways, GHG emissions will decrease over the same period due to reduced demand for cereals, whereas significant crop productivity and harvest intensity gains would lead to increased crop production. The exercise reveals the indispensability of healthy diets, improved crop, and livestock productivity, and net-zero deforestation in achieving India's mid-century emission targets from the agriculture sector. Supplementary Information: The online version contains supplementary material available at 10.1007/s11625-022-01193-0.

A Systematic Review and Meta-analysis of Touch Imprint Cytology and Frozen Section Biopsy and Their Comparison for Evaluation of Sentinel Lymph Node in Breast Cancer.

INTRODUCTION: Evaluation of axillary lymph nodes after sentinel lymph node biopsy (SLNB) in breast cancer is mostly done by intra-operative frozen section biopsy (FSB) and/ or touch imprint cytology (TIC). In this systematic review and meta-analysis, we have compared the accuracy of the two modalities. METHODS: PubMed, EMBASE, and Cochrane electronic databases were searched for articles comparing TIC with FSB. Articles were assessed for methodological and reporting quality. The main summary measures were pooled sensitivity, pooled specificity, and diagnostic accuracy using bivariate generalized linear mixed models using random effects. RESULTS: Fourteen studies were included. The pooled sensitivity, specificity, and diagnostic accuracy for FSB were 78%, 100%, and 98.57%. For TIC, the pooled sensitivity, specificity, and diagnostic accuracy were 74%, 98%, and 98.37%. For both methods, visual inspection of summary ROC curves and of forest plots did not show significant heterogeneity. CONCLUSION: TIC showed comparable sensitivity, specificity, and accuracy to FSB and hence can be used as its substitute as a rapid and economical test for the detection of axillary lymph node metastasis during SLNB especially in low-resource settings.

Truncal Ligation of Inferior Thyroid Artery Does Not Affect the Incidence of Hypocalcaemia After Central Compartment Lymph Node Dissection.

Preserving all parathyroids with intact blood supply in situ is a desirable goal while performing total thyroidectomy (TT) and central compartment dissection (CCLND), but the same is not feasible in presence of bulky and/or matted lymph nodes in the central compartment. The aim of this study was to investigate the difference in incidence of postoperative hypocalcemia between the groups of papillary thyroid carcinoma (PTC) patients who had truncal ligation (TL) versus ligation of peripheral branches (PL) of inferior thyroid artery (ITA) during TT and CCLND. Retrospective review of prospectively kept data of PTC patients undergoing TT and CCLND. Patients were divided in two groups: Group 1-(n = 57) patients who had to undergo TL and Group 2-(n = 99) patients having PL. Clinico-pathologic profile, operative details and follow-up events were noted. Clinico-pathologic profile of both groups was comparable except for higher incidences of tumor multicentricity (p = 0.014) in Group 1. There was no significant difference in the number of parathyroids identified between the Groups (p = 0.556) but more parathyroids were auto-transplanted in Group 1 (p = 0.001). The incidence of temporary (77.2% vs 83.8, p = 0.304) and permanent hypocalcemia (7% vs 8.1%, p = 0.810) was not significantly different between the groups and neither was need for intravenous calcium. At discharge, Group 1 patients received lower dose of calcium (p = 0.001) but not of vitamin D (p = 0.769). TL of ITA during CCLND does not result in increased temporary or permanent hypocalcemia rate.

Acute inflammatory response to multiple chemotherapy regimen in breast carcinoma: An unreported entity1.

Increased utilization of chemotherapy in breast cancer patients has led to improved survival outcomes but it has also resulted in rising incidence of adverse effects. Occurrence of new/unreported side effect poses challenge in front of clinicians. We report the case of a 53-year lady with locally advanced, hormone receptor-positive, and human epidermal growth factor-2 (HER-2) negative right breast carcinoma. She was started on neoadjuvant chemotherapy (NACT) (doxorubicin and cyclophosphamide), to facilitate breast-conserving surgery. She developed an inflammatory reaction involving the affected breast after each of three cycles of NACT (2 cycles of doxorubicin & cyclophosphamide, and 1 cycle of docetaxel). Infectious causes and disease progression were ruled out. She was then prescribed hormone therapy but the disease progressed after three months of therapy and the patient had to be subjected to modified radical mastectomy (MRM). She then received adjuvant radiotherapy and is currently doing well on second-line hormone therapy.

Stannylene cyanide and its use as a cyanosilylation catalyst.

Two routes can offer the first stannylene cyanide [(L)SnCN] (5); the substitution reaction of either stannylene amide [(i-Bu)2ATISnN(SiMe3)2] (3) or stannylene pyrrolide [(i-Bu)2ATISn(NC4H4)] (4) using an excess of trimethylsilyl cyanide (L = aminotroponiminate (ATI)). Using 0.1-2.0 mol% of compound 5, catalytic cyanosilylation of a variety of aliphatic and aromatic aldehydes was achieved at rt-50 °C in 0.33-2.0 h. The mechanism of this catalytic reaction is authenticated by the isolation of a structurally characterized intermediate.

Barriers and challenges in providing standard breast cancer care in low resource settings.

In this study, we investigated the barriers to the delivery of internationally accepted breast cancer care in low resource settings (LRS) as compared to well-endowed resource settings (WRS) via an online survey. The survey was completed by 199 surgeons from eleven countries: 51 from WRS and 148 from LRS, based on our definition. The two most common facilities lacking in LRS were sentinel lymph node biopsy and immune-histochemistry (67% and 60% respectively). Only 22% respondents from LRS confirmed that all their eligible patients received hormonal therapy and only 8% radiotherapy as compared to 98% and 75% from WRS. Widespread limitations exist in most LRS, making internationally accepted breast cancer treatment guidelines impossible to follow, and thus resulting in suboptimal cancer care.