Mainstreaming genetic counseling for BRCA testing into oncology clinics - Indian perspective.

BReastCAncer (BRCA) susceptibility genes BRCA1 and BRCA2 are mainly associated with hereditary breast and ovarian cancer (HBOC) syndrome and present an estimated 45%-65% cumulative lifetime risk of developing breast cancer and an 11%-39% risk of ovarian cancer. HBOC is also linked to triple-negative breast cancer (TNBC). BRCA1 mutations in TNBC are observed in 36% of women age <40 years and 27% of women age <50 years. In India, the prevalence of BRCA1/2 mutation varies from 2.9% to 38% among families with genetic predisposition toward hereditary cancers. With HBOC being linked to early-onset breast cancer and increased susceptibility to other cancers, early screening for BRCA mutations has become a pressing need. Though genetic counseling (GC) for BRCA mutation testing is common in most of the developed countries, India still faces several challenges in mainstreaming the same. Many barriers to effective GC for BRCA testing are unique to India. There is a dearth of trained geneticists which puts the pressure on oncologists to give GC for which they neither have the time or training. Presence of multiethnic/linguistic population acts as a major hindrance along the way toward development of robust predictive and effective GC models for BRCA testing. The current review discusses the need and benefits of GC in breast cancer prevention, through BRCA testing, from an Indian perspective. The functional framework of GC and the role of genetic counselors are discussed in detail. In addition, importance of GC training and role of a multidisciplinary team approach for mainstreaming pre- and post-BRCA test GC is highlighted.

Isolated Midbrain Metastasis from Breast Cancer: a Classic Spotter Diagnosis.

Isolated midbrain metastasis from breast cancer is a rare occurrence. We present a classical clinical image of a woman who presented with breast cancer with synchronous isolated midbrain metastasis.

Pinch-Off Syndrome and Fracture Embolization: a Preventable Complication of TIVADS.

Totally implantable venous access device has become indispensable in oncology. One of the well-known complications of the subclavian approach is the pinch-off syndrome. We hereby describe how a case of pinch-off syndrome with catheter fracture and embolization into the heart was managed by prompt endovascular intervention.

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience.

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Cervical Cord Compression as Initial Presentation of Papillary Thyroid Carcinoma: a Case Report.

Cervical cord compression secondary to extension of a long standing papillary thyroid carcinoma as well as multiple cases of distal cord compression from occult follicular thyroid carcinoma have been reported. But cervical cord compression from Papillary Thyroid Carcinoma has not been reported so far. Forty eight year old lady presented with progressive quadriparesis of 2 months duration. MRI of the cervical spine showed destructive lesion with soft tissue component in vertebral bodies and posterior elements of C4-C6 vertebrae with cord compression along with a large thyroid mass extending to retrosternal region likely malignant. USG guided FNAC & Biopsy of thyroid lesion was inconclusive. She underwent Preoperative Selective angioembolisation for vertebral metastasis followed by total thyroidectomy with cervical cord decompression, bone grafting and plating. HPE reported follicular variant of Papillary Thyroid carcinoma. Four weeks postoperatively she underwent radioiodine ablation by 263 mci of I 131. She then received palliative EBRT to cervical and dorsal spine 30 Gy/10 fractions. She is alive and neurologically stable at 6 months follow up. Papillary thyroid carcinoma has an excellent prognosis. Hence a prompt management of primary disease and aggressive approach to metastatic lesion may prolong survival and allow favorable prognosis.

Sternal Resection and Reconstruction for Malignant Phylloides Tumor.

Malignant phylloides tumor is a locally aggressive breast neoplasm constituting less than 1 % of all breast cancers. It has a tendency for local recurrence and management is multidisciplinary. We hereby report a case of total sternal resection and reconstruction using Biopore HDPE prosthesis for Malignant Phylloides tumor.

Resection after neoadjuvant chemotherapy in advanced carcinoma of the gallbladder: a retrospective study.

Although rare over most of the world, Gallbladder cancer is very common in northern india. A delayed presentation, aggressive nature,lack of randomised trials and a poor prognosis have all contributed to the nihilistic halo encircling gallbladder cancer. None of the advances in oncology have been exploited enough to shatter the nihilistic halo. In this background we sought to analyze if the addition of neoadjuvant chemotherapy had any impact on the resectability, overall and disease free survival in patients with advanced carcinoma of the gallbladder. We reviewed the records of all patients who underwent surgery for carcinoma of the gall bladder from 2004 to 2010 at our institute retrospectively. Twenty-one patients received neoadjuvant chemotherapy and subsequently taken up for surgery. Outcome analysis of these 21 patients were done by Kaplan meier method and graphs plotted. Out of the 21 patients who were taken up for surgery after neoadjuvant chemotherapy, fourteen patients underwent R0 resection (Group 1). Seven patients had been rendered inoperable on exploration (Group 2). Thus about 66.67 % of patients deemed resectable after neoadjuvant chemotherapy on imaging underwent R0 resection. The mean overall survival of the group 1 was 42.8 months versus 6.6 months of group 2(Hazard Ratio: 3.42). Neoadjuvant chemotherapy improves resectability in some patients with unresectable gall bladder cancer. Resection after neoadjuvant chemotherapy is feasible and may improve survival in a select group of patients. However randomized studies are required to establish its definitive role.

Radical Esophagectomy After Neoadjuvant Chemoradiation: Single Institutional Experience from Tertiary Cancer Centre in India.

Although preoperative chemoradiation has shown to improve surgical outcomes in both loco-regional control and long term survival; it has still not become the standard of care in many centers. There is reluctance in accepting preoperative chemoradiation primarily due to fear of increased perioperative morbidity/mortality or non-availability of infrastructure and expertise. We present a retrospective analysis of our results of radical esophagectomy after neoadjuvant chemoradiation. All patients who underwent Radical Esophagectomy from January 2009 to December 2013 by a single surgical team at our institute were included in the series (n = 118). Patients undergoing surgery after chemo-radiation (group A = 66) were compared with those under going upfront surgery (group B = 52) in terms of patient variables (age, sex, comorbidities, tumor location, staging, histology) and postoperative surgical outcomes and complications using Chi square test. Overall and disease free survival was analyzed using Kaplan Meir curve. There was no difference in duration of surgery, postoperative stay and overall morbidity and mortality in both groups. Although group A patients had more of advanced cases clinically, but histopathology showed complete pathological response (pCR) in nearly 40 % patients and negative nodes (pN0) in 62.5 % patients. OS and DFS showed a trend towards better survival with preoperative chemoradiation. We conclude that radical esophagectomy after preoperative chemoradiation is feasible and safe in developing countries. Moreover pathological complete response correlates well with improved survival. Randomized control trials may be required to further substantiate the results.