Patient Reported Financial Distress and its Association with Quality of Life and Symptom Burden in Cancer Patients Reporting to a Public Facility in LMIC

PURPOSE/OBJECTIVE(S)

Financial distress (FD) associates with worse quality of life (QoL) and there is paucity of literature from low middle income setting (LMIC). We investigated the prevalence & impact of subjective FD on QoL & symptom burden in advanced cancer patients, reporting to a public facility.

MATERIALS/METHODS

Patients aged ≥18yrs with a diagnosis of cancer within 3months and without prior treatment were accrued. Subjective FD was assessed by EORTC QLQ-C30 and symptoms were assessed by ESAS-R at baseline and 3 months. Patients were classified as experiencing FD if they answered ≥2 on a Likert scale question (1-4 points) asking about FD and dichotomized as Grp 1: No FD and Grp 2: FD. Mean change in score was calculated by subtracting the baseline from the 3-month score for each subscale, minimal important difference (MID) was defined using an anchor of ≥ 10-point compared to baseline for Global Qol and compared between groups. We used Mann Whitney, independent sample t test and Fisher's exact test for determining the association between FD and QoL and symptom burden. A p-value < 0.05 was considered statistically significant.

RESULTS

Of the 100 patients participating in the study, 69% reported subjective financial distress at baseline, 10% had insurance coverage, 27% used distressed financing (borrowing :21%; sold off assets:6%) and debt accumulation was seen in 34% patients. Cost reduction strategies were adopted by 98% patients. Mean Global Health (GH), physical (PF), emotional function (EF) was significantly worse at all time-points in FD patients. Physical (pain, tiredness) and psychological symptom scores (anxiety, depression) were significantly higher at all time points for FD patients. Mean change score for subscales of QoL and symptom burden was not significantly different between groups from baseline to 3 months (Table1).MID for deterioration of Global Qol was Grp 1 vs 2; 21.1% vs 32.7%, p = 0.504.

CONCLUSION

Two-thirds of patients have FD at presentation and report worse quality of life and symptom burden at all time-points. Presence of FD is not associated with significant change in QoL scores or symptom burden over 3 months. Measures are warranted to screen and reduce FD.

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

An inguinal enigma: Myxoid liposarcoma in a female

Myxoid liposarcoma of the inguinal region is rare, can mimics an inguinal hernia. Any swelling in the inguinal region, that is partially reducible, fluctuant, soft, and without any signs of bowel obstruction should be evaluated further.

Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression-a case report

Background

Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer.

Case presentation

A 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later.

Conclusion

Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Epiploic Appendagitis: A Riddle for Right Lower Quadrant Pain!

Epiploic appendagitis (EA) is inflammation of epiploic appendages, which are pedunculated fatty structures, extend from the cecum to the rectosigmoid junction, and are covered by the peritoneum. Torsion, infarction, and inflammation of it present with acute lower abdominal pain and localized tenderness in a well-looking patient. It poses as diagnostic conundrum due to its rarity and not picked by conventional radiography. A 50-year-old male presented with pain in RLQ for past 1 day, which kept on increasing without any other symptoms. His abdomen was soft with tenderness localized to the right lower quadrant (RLQ), classically at McBurney's point along with mild peritonism. Rest laboratory test, chest, and abdominal X-ray were normal except slight leukocytosis. Ultrasound was inconclusive. A working clinical diagnosis of appendicitis was made. Patient did not consent for surgery and was started on antibiotics with pain killers. With no significant improvement, he underwent CT scan which revealed focal area of soft-tissue attenuation along the lateral wall of ascending colon with fat stranding. He was diagnosed as EA and improved on conservative treatment. EA of RLQ of abdomen mimics acute appendicitis and can be considered as an uncommon differential diagnosis in presence of radiological findings of normal-appearing appendix. CT is the investigation of choice, and treatment is essentially conservative. Further, if appendix is found normal at exploration, surrounding epiploic appendages of the cecum and ascending colon should also be evaluated carefully for inflammation/hematoma/gangrene, besides looking for Meckel's diverticulum.

Ten years since the crises in Syria: lessons for planetary and public health

Climate scientists have attributed the war in Syria to persistent droughts caused by damming of rivers and growing aridity due to climate change. As result of the war, there has been widespread migration, hunger, malnutrition, and a collapse of public health systems. While many climate researchers question the direct link of climate variability to civil unrest, there is no doubt that mitigating and reversing Syria's environmental degradation, and reviving food security and public health systems will play an important role in avoiding future unrest in the region.

Ovarian inguinal hernia - a possibility in MURCS syndrome

Background

Inguinal hernia containing ovary and fallopian tube can be found in paediatric population and is a rare finding in women of reproductive age group. Most of the cases are associated with congenital abnormalities of the female genital tract.

Case presentation

A 20 year old female presented with right reducible inguinal hernia, primary amenorrhea and normal secondary sexual characteristics. Clinical examination revealed scoliosis with convexity towards left side, prominence of left rib cage with Sprengel deformity and right sided heart sounds. Ultrasound of the inguinal swelling revealed right ovary within the hernial sac, Chest X-ray revealed right lung collapse and dextrocardia. Further Magnetic resonance imaging (MRI) of pelvis revealed inguinal hernia with right ovary as its content, normal left ovary and absent uterus. Computed tomography (CT) revealed complete collapse of right lung with compensatory left lung hyperinflation and absent right kidney. Karyotyping of the patient was normal, 46XX. A diagnosis of MURCS syndrome with right ovarian hernia was made. The hernia was surgically managed with repositioning of ovary and fallopian tube into the pelvis.

Discussion

Ovary in inguinal hernia is rare in women of reproductive age group. MRKH syndrome, a mullerian duct anomaly, is the congenital aplasia of uterus and upper two-thirds of vagina in a female with normal ovaries, fallopian tube, secondary sexual characteristics and 46XX karyotype. MURCS is a subtype of MRKH type 2 having mullerian duct agenesis with renal, cardiac, muscular & vertebral defects. General physical examination and primary investigations if yields abnormal findings; the patient must undergo an array of investigations to rule out MRKH/MURCS, or other congenital abnormality. Early diagnosis is essential to prevent its incarceration or torsion. The primary treatment of ovary in inguinal hernia is repositioning the ovary and fallopian tube back to pelvis to preserve fertility and repair of inguinal hernia. A multidisciplinary team is required to deal with various abnormalities present in a patient with MURCS.

Role of intra-abdominal pressure in the outcomes of perforation peritonitis: A prospective observational study

OBJECTIVES

Intra-abdominal pressure (IAP) has been investigated for its role in causing morbidity and mortality, with various studies showing different degrees of correlation. There remains paucity of literature on this subject, applied to patients of perforation peritonitis, especially in the Indian subcontinent.

MATERIAL AND METHODS

It is a prospective observational study involving 40 patients of perforation peritonitis undergoing exploratory laparotomy. IAP was measured as per WSACS (World Society of Abdominal Compartment Syndrome) guidelines. APACHE II (Acute Physiology And Chronic Health Evaluation- II) and SOFA (Sequential Organ Failure Assessment) were calculated. Data was collected regarding occurrence of prolonged ileus, burst abdomen, duration of hospital stay, 30 day mortality, and was statistically analyzed to correlate with IAP.

RESULTS

At admission, mean IAP was 13.37 mmHg, and the incidence of IAH was 65%. IAH was seen in 17.9% and 7.6% at 24 h and 48 h post-operatively. Incidence of prolonged ileus and burst abdomen were 7.7% and 22.5% respectively. Mortality rate was 17.5%. Mean duration of hospital stay was 13.45 days. Post-operative IAP correlated with mortality (p: 0.014) and post-operative SOFA score (p <0.05). Statistically significant correlation was also seen with the occurrence of prolonged ileus (p: 0.006). IAP did not significantly correlate with APACHE II score, occurrence of burst abdomen, and duration of hospital stay.

CONCLUSION

Rise in IAP correlates with deterioration of SOFA score, and also with the occurrence of prolonged ileus. IAP is also a predictor of mortality. IAP measured post-operatively (24 and 48 hours) had a better correlation with these outcomes than the value measured at admission. No statistically significant correlation of IAP with the occurrence of burst abdomen and duration of hospital stay could be found, which warrants further studies with a larger population.

Inverted Meckel's diverticulum: a case report

Background

Inverted Meckel’s diverticulum refers to the condition in which the diverticulum inverts on itself. The reasons for such an inversion are poorly understood due to the rarity of the condition. We present a case of inverted Meckel’s diverticulum, an uncommon finding, as a cause of recurrent intussusception.

Case presentation

A 30-year old Indian woman presented with complaints of pain in the central abdomen for 3 days, accompanied with vomiting and loose stools. Computed tomography images were suggestive of intussusception with intestinal obstruction. Intra-operative findings were suggestive of an intussuscepted segment of ileum measuring 10 cm in length, proximal to ileocecal junction. Ileo–ileal anastomosis was performed after appropriate resection. Upon opening the specimen, we were surprised to find an inverted Meckel diverticulum with lipoma at one end causing the intussusception. The patient made an uneventful recovery and was discharged after 5 days.

Conclusion

The reasons for inversion include abnormal peristalsis around the diverticulum and non-fixity of the diverticulum itself. The inverted diverticulum itself can cause luminal compromise and acts as a lead point for intussusception leading to obstruction. Computed tomography remains the diagnostic tool of choice for identifying intestinal obstruction and intussusception. Although pathological signs, such as lipoma, can be identified, the identification of any inversion will require a proficient radiologist. Inverted Meckel’s diverticulum is a rare condition which is difficult to diagnose preoperatively. Treatment is surgical, whether diagnosed pre-operatively or intra-operatively, and includes segmental resection and anastomosis. This uncommon condition should be noted as one-off differential diagnosis for intussusception and intestinal obstruction.

Giant bilateral angiomyolipoma of the kidney

Angiomyolipoma is a benign solid renal neoplasm. A giant angiomyolipoma is more than 10cm by size, but it can grow to huge proportions. Our case appears to be the third largest angiomyolipoma and the largest among bilateral giant renal angiomyolipoma in the indexed literature. A 26-year-old man presented with large right abdominal swelling for the past three years, which was occupying his right flank and iliac region, extending beyond the midline. Computed tomography of the abdomen revealed a large well-defined mass in the right side of the abdomen, crossing the midline and measuring 35 × 20 × 12cm. The left kidney showed a similar fatty lesion of 14 × 6cm. The findings were consistent with angiomyolipoma. Further evaluation for tuberous sclerosis by magnetic resonance imaging the brain demonstrated multiple subependymal nodules. Giant renal angiomyolipoma is an uncommon tumour with bilateral giant angiomyolipoma being a rare entity. Preoperative embolisation helps in reducing size of the tumour. In case of giant and bilateral angiomyolipoma, evaluation for tuberous sclerosis should always be done.

Oral Lactulose vs. Polyethylene Glycol for Bowel Preparation in Colonoscopy: A Randomized Controlled Study

Background

Colonoscopy is the method of choice to evaluate colonic mucosa and the distal ileum, allowing the diagnosis and treatment of many diseases. Appropriate bowel preparation necessitates the use of laxative medications, preferentially by oral administration. These include polyethylene glycol (PEG), sodium picosulfate, and sodium phosphate (NaP). Lactulose, a semi-synthetic derivative of lactose, undergoes fermentation, acidifying the gut environment, stimulates intestinal motility, and increases osmotic pressure within the lumen of the colon.

Methods

In this prospective randomized controlled study, we analyzed 40 patients who presented with symptomatic bleeding per rectum and underwent bowel preparation either with lactulose or polyethylene glycol for colonoscopy. The quality of bowel preparation and other variables like palatability, discomfort, and electrolyte levels were analyzed.

Results

The majority of the patients (90%) were comfortable with the taste of lactulose solution, whereas the PEG group patients (55%) were equally divided on its palatability. On lactulose consumption, 40% of patients reported nausea/vomiting and around 10% of patients complained of abdominal discomfort. Serum sodium levels showed insignificant changes from 4.33 ± 0.07 mEq/L to 4.21 ± 0.18 mEq/L while potassium also remained similar from 4.26 ± 0.03 mEq/L to 4.22 ± 0.17 mEq/L. The mean Boston Bowel Preparation Score (BBPS) in patients who received lactulose solution was 6.25 ± 0.786 and in those who received PEG solution, it was 6.35 ± 0.813 (P-value = 0.59).

Conclusions

Lactulose is a significantly more palatable form of bowel preparation and causes minor discomfort. It has a good bowel cleansing action comparable to PEG without causing any hemodynamic changes. It can be considered a cheaper and safe alternative for bowel preparation in colonoscopy in low-resource settings.

The giant resectable carcinoma of gall bladder-a case report

Background

Gall bladder cancer (GBC) is the fifth most common malignancy in the gastrointestinal system and the most common malignancy of the biliary system. GBC is a very aggressive malignancy having a 5 year survival rate of 19%. Giant Gall Bladder (GGB) is an uncommon condition that can result from cholelithiasis or chronic cholecystitis and rarely with malignancy.

Case report

A 65 year old lady presented with vague abdominal pain for 12 years and right abdominal lump of size 20 × 8 cms was found on examination. CT scan showed a circumferentially irregularly thickened wall (2.5 cm) of gall bladder indicative of malignancy. Per-operatively a GB of size 24 × 9 cm was noted and patient underwent radical cholecystectomy. It was surprise to find such a giant malignant GB with preserved planes. Histopathology, it was well differentiated adenocarcinoma of gall bladder of Stage II (T2a N0 M0).

Discussion

It is known that mucocoele of GB can attain large size, however chronic cholecystitis will lead to a shrunken gall bladder rather than an enlarged one. A malignant GB of such size and resectable is rare without any lymph node involvement or liver infiltration. Few cases of giant benign gall bladder have been reported in literature, however this appears to be the largest resectable gall bladder carcinoma reported till date as per indexed literature.

Conclusion

Giant GB is an uncommon finding. They are mostly benign, however malignant cases can occur. Radiological findings may suggest features of malignancy and define extent of disease. Prognosis depends on stage of disease and resectability, irrespective of size.

Negative pressure wound therapy in grade 1 and 2 diabetic foot ulcers: A randomized controlled study

BACKGROUND AND AIMS

Foot ulcers are one of the major causes of morbidity and mortality among diabetics in India. Early diagnosis and timely management is vital in preventing the progression of the disease which may require amputation. Conventional methods take a long time for healing. This study aims to compare negative pressure wound therapy (NPWT) and conventional saline dressings in diabetic foot ulcer (DFU) healing.

METHODS

This prospective randomized study was conducted in 45 patients with grade 1 and 2 DFUs. 22 patients in group A received NPWT and 23 patients in group B received saline dressings. The formation of granulation tissue, reduction in ulcer size, duration of hospital stay and time for complete healing of wounds were assessed.

RESULTS

The formation of granulation tissue (91.14 vs 52.61%, p < 0.001) and reduction in ulcer size (40.78 vs 21.18%, p = 0.008) at 14 days was significantly more in group A. The duration of hospital stay (15.68 vs 29.00 days, p < 0.001) and time for 100% coverage of the wound with granulation tissue (14.82 ± 7.30 vs 44.57 ± 7.11 days, p < 0.001) was significantly less in group A. Complete healing of wounds at 3 months was observed in 20 patients (90.9%) in group A and 6 patients (26.1%) in group B (p = 0.006).

CONCLUSION

In our study NPWT led to early reduction in ulcer size, more granulation tissue formation, shorter hospital stay and complete wound healing. In lower and middle income countries like India with high prevalence of DFUs, early recovery is a boon to the patients to resume their daily activities.

Comparison of gustatory function between mucosal and squamous disease: a randomised controlled study

OBJECTIVE

The aim of this study was to evaluate and compare the gustatory function between patients with chronic mucosal and squamous diseases before and after the surgery.

METHOD

A total of 33 patients with mucosal diseases and 34 patients with squamous diseases were evaluated for gustatory function both in the pre-operative and post-operative periods. The taste scores were compared between the two groups.

RESULTS

The gustatory scores in the mucosal disease group were significantly better than the scores in the squamous disease group (p < 0.05). There was no significant correlation detected between the age of the patients or duration of the disease with the taste scores in any of the study groups.

CONCLUSION

The improvement in gustatory score was better in the chronic mucosal disease group than the squamous disease group. There was no significant correlation found between the age of the patients or duration of disease and the taste score in any of the study groups.

Small bowel knots

INTRODUCTION

Intertwining of bowel loops to form a knot is very rare cause of intestinal obstruction. Among intestinal knots, ileoileal knotting is the most rare, with only a handful of cases reported in literature. We present a rare case of ileoileal knotting and review of small bowel knots. The aim of this review was to summarise the existing evidence on small bowel knots and to postulate the possible mechanisms for knotting.

METHODS

A systematic search was conducted for literature published up to December 2019 using MEDLINE, PubMed and Google Scholar databases, together with the references of the full-text articles retrieved. Papers with case reports of small bowel knots were considered to be eligible for inclusion in the review.

FINDINGS

A total of 14 case reports were evaluated. There was no clear predilection for age or sex. Mostly cases were from Asia and Africa with no cases from the West. The presenting complaints were abdominal pain (93%), vomiting (64%), abdominal distention (57 %) and obstipation (43%). The bowel was gangrenous in 78% of cases. All underwent exploration, with the majority requiring resection and anastomosis of the involved segment.

CONCLUSION

Ileoileal knotting is a very rare cause of intestinal obstruction. Possible mechanisms include loaded bowel with longer mesentery, vigorous peristalsis, single bulky meal, pregnancy and intussusception. The condition is extremely difficult to diagnose preoperatively and it is usually diagnosed intraoperatively. The standard of treatment is resection of gangrenous part and anastomosis.

Attitude and Beliefs About Surgical Safety Checklist in a North Indian Tertiary Care Hospital a Decade Later of WHO Checklist.. [DOI: 10.21203/rs.3.rs-32202/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Avoidable surgical complications account for a large proportion of preventable medical injuries and deaths globally. Surgical Safety Checklist is evidence-based, internationally accepted valid instrument, which has been found to reduce postoperative morbidity and mortality; the benefits of which are most striking in low- and middle-income countries (LMICs) Despite implementation in many hospitals throughout the country, there is still lack of awareness and concern in many LMICS health care facilities towards SSCL and its use, even after a decade of WHO checklist. We conducted a survey to assess the knowledge, attitudes and beliefs about the WHO-surgical checklist in which 65.4% (138) surgeons, 25.1% (53) anaesthetists and 9.5% (20) nurses participated. Majority believed that use of SSCL improves the safety of procedures, improves communication amongst theatre staff and will result in a reduction in errors in theatre yet there was no commitment for use of SSCL. Although all theatre personnel support implementation and use of SSCL however hierarchical issues, lack of administrative support, lack of training, logistics and timing, high patient volume and overburdened residents, lack of co-ordinator or leadership role and shortage of man power can be impediment to effective use. Nurses and junior doctors play a crucial role. Commitment rather than compliance and teamwork will be the key, ably supported by education and training which should be mandatory for all OT stake holders. Therefore, any measure that can potentially improve patient safety should be embraced and benefits of SSCL be told to motivate them and enhance participation for patient safety. Committed leadership, knowledge sharing and periodic trainings, interdisciplinary communication, feedback and regular audits can define and determine effective implementation process.

A case report of carcinoma of uterine cervix throwing heterochronous metastasis to the skin, spleen, and pancreas: the role of multimodality treatment approach

BACKGROUND

Cancer of cervix often fails locally and/or within the pelvis. One to two percent of cervical squamous cell carcinoma patients have lung metastases at presentation, and 5-35% develop pulmonary metastases later on. Common sites of metastases are the liver, bone, and bowel. We report a rare case presentation of cervical squamous cell cancer where heterochronous metastasis occurred in the skin, spleen, and pancreas without loco-regional recurrence and skipping of visceral organs such as the lung, liver, and brain.

CASE PRESENTATION

A 55-year-old, postmenopausal lady presented with a complaint of bleeding of the vagina for 2 months duration. Cervical biopsy revealed squamous cell carcinoma of the cervix, and she was staged as a case of FIGO stage IIIB. She received external beam-beam radiotherapy of 50 Gy in 25 fractions along with concurrent weekly cisplatin at 35 mg/m² followed by 3 fractions of intracavitary brachytherapy of 6 Gy each. After 30 months of follow-up, she presented with a skin lesion of 6 × 5 cm² in the infrascapular region for 2 months duration. Biopsy revealed metastatic squamous cell carcinoma. Her metastatic work-up revealed no other lesions. Palliative radiotherapy to local site of 8 Gy in single fraction was delivered. The lesion disappeared within 4 weeks. She was given 6 cycles of cisplatin and paclitaxel salvage chemotherapy. After 30 months of follow-up, she presented with a skin lesion of 6 × 5 cm² in the infrascapular region. Biopsy revealed metastatic squamous cell carcinoma. Her metastatic work-up revealed no other lesions. Palliative radiotherapy to the local site was planned, and a dose of 8 Gy in a single fraction was delivered. The lesion disappeared within 4 weeks. She was given 6 cycles of cisplatin and paclitaxel salvage chemotherapy. Six months after the completion of salvage therapy, she reported with the complaints of recurrent bouts of hematemesis and melena. Her CECT scan revealed 2 × 1.5 cm² growth in the body of the pancreas and a subcentric splenic hilum node. She underwent open splenectomy with distal pancreatectomy. Histopathology report showed metastatic infiltration in pancreatic tissue by squamous cell carcinoma and one metastatic node in the splenic hilum. Post-treatment, 6 months, the patient was asymptomatic with no recurrence.

CONCLUSIONS

This is a rare heterochronous metastatic presentation of cervical cancer without loco-regional recurrence and visceral organs such as the lung, liver, and brain. The optimal treatment remains undefined for these patients. Multimodality treatment is necessary to manage the patients.

Zinner syndrome mimicking bladder outlet obstruction managed with aspiration

Zinner syndrome is a rare cystic malformation of seminal vesicle which consists a triad of unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction. The usual presentation is between the third and fourth decades of life, with infertility being the most common complaint. Ultrasound, cystoscopy, and magnetic resonance tomography (MRI) can easily detect this condition. Treatment option varies according to the presenting symptoms of the patient. We present a case of a 19-year-old male with recurrent episodes of urinary tract infection (UTI) and poor urinary stream. On ultrasound examination, the patient was found to have absent right kidney with a cystic swelling noted to be arising from prostate or seminal vesicle region which was further confirmed on MRI examination. Cystoscopy reveals a bulge on the right side of the verumontanum abutting the neck of the bladder. An ultrasound-guided aspiration of the cyst was performed which relieved the symptoms of the patient. Cystic abnormalities of the seminal vesicle are very uncommon. Symptomatic cases may present as recurrent UTI, infertility, bladder outlet obstruction, and painful ejaculation. Surveillance may be the option in the absence of clinical manifestations. Interventions such as image-guided aspiration or surgical procedures are appropriate when conservative measures prove ineffective.

A large ureteric calculus: is there a role for open surgery in the modern era?

A 36 year old gentleman presented with recurrent urinary tract infections, hematuria and lump in the left side of abdomen for 4 months. Clinically a soft, non-tender lump in left lumbar region with well-defined margins was palpable. CT scan of abdomen revealed a calculus of size 45 mm at the left vesico-ureteric junction with gross left hydronephrosis. Patient underwent open ureterolithotomy in view of the large size of calculus and due to stone impaction. Post-operative period was uneventful. Patient was followed up for 6 months and remained asymptomatic.

Isolated primary cold abscess of the sternum: a case report

Background

Musculoskeletal tuberculosis forms 10–25% of extrapulmonary tuberculosis which mainly involves the spine or weight-bearing joints. Tuberculous involvement of the sternum is a rare clinical entity even in countries where tuberculosis has high prevalence. Primary tuberculous sternal osteomyelitis accounts for approximately 0.3% of all types of tubercular osteomyelitis and the probable source appears to be extension from paratracheal or hilar lymph nodes. Despite tuberculosis being a common disease in endemic countries and worldwide, a thorough literature search of the PubMed database for keywords “primary tuberculosis of sternum” and “primary tuberculous osteomyelitis of sternum” yielded 30 and 22 articles, respectively.

Case presentation

We present an unusual case of a large dumb-bell-shaped cold abscess arising due to infection of the sternum. A 23-year-old immunocompetent Asian woman presented with a gradually progressing painless swelling on anterior chest wall for the last 5 months. She had a large visible swelling on anterior chest wall which was 12.5 cm in diameter, soft, non-tender, temperature was not raised, and fluctuant. Magnetic resonance imaging showed a large dumb-bell-shaped hyperintense collection in upper anterior chest wall with marrow edema and cortical irregularity in left side of manubrium. Pus was positive for nucleic acid testing (cartridge-based nucleic acid amplification test) for Mycobacterium tuberculosis and later culture was also positive. She was started on anti-tubercular therapy and aspirated twice. Currently, she has completed 6 months of therapy and the swelling has now disappeared.

Discussion

Swelling, pain localized to sternum, or ulceration of the skin with discharging sinus along with or without constitutional symptoms are the usual presentation. A high element of suspicion is needed for early diagnosis and treatment to prevent its complications. Sternal mycobacterial infections are categorized as primary, secondary, and/or acquired postoperatively. Although radiological investigations aid in diagnosis, the diagnosis is established by positive culture or histopathological examination. Anti-tubercular therapy is the mainstay of treatment with standard four-drug regimen for 6–9 months. Surgical drainage of the abscess should be considered only if it does not resolve by aspiration and anti-tubercular therapy.

Giant filarial retroperitoneal cyst: a diagnostic dilemma

Background

Filarial infections are common in most tropical and subtropical regions of the world. Lymphatic filariasis is caused by either Wuchereria bancrofti, Brugia malayi, or Brugia timori. Extralymphatic filariasis presenting as a primary retroperitoneal mass is very rare despite filariasis being endemic in many regions of India. On review of literature, only a few isolated case reports have been described.

Case presentation

We report a case of a huge retroperitoneal cystic mass in a 46-year-old patient who presented with a long-standing, painless progressive abdominal swelling. On examination, there was a large, non-tender, firm swelling of size around 20 × 15 cm occupying the left upper and lower quadrant. The computed tomography of the abdomen was suggestive of thin-walled hypodense cyst of size 25.7 × 15 × 14.3 cm. Laboratory investigations and cyst aspirate were inconclusive for a definite diagnosis. On exploration, a 3-kg cystic mass was removed. The diagnosis of filarial origin was confirmed by the demonstration of microfilaria in the cyst wall and immunochromatographic test (ICT) which was positive.

Conclusion

Retroperitoneal lymphatic cyst of filarial origin is very unusual and requires a high index of suspicion if the patient is an inhabitant of an endemic area. The clinical dilemma cannot be resolved with imaging modalities alone, unless a disease-specific manifestation is there. The retroperitoneal cysts often pose a challenge in their diagnosis and management. Small cysts might respond to medical management, whereas large symptomatic cysts will require excision for the final diagnosis and treatment.

Abstract P1-15-11: Predicting pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) based on pre- and post-NACT digital mammography and digital breast tomosynthesis findings

Background: In invasive breast cancer patients being treated with neoadjuvant chemotherapy (NACT), achieving pathological complete response (pCR) is a useful goal of treatment. Monitoring response to NACT and predicting pCR is helpful in planning further therapy and providing robust prognostic information. Digital mammography (DM) and additional digital breast tomosynthesis (DBT) features are important tell-tales of tumor characteristics and behaviour. Following NACT, the mammographic features- both DM and DBT- of responding tumors can vary considerably. In this prospective study, we correlated the DM and DBT features of pre-NACT and post-NACT mammograms to investigate if these can reliably predict pCR to NACT.

Methods: Following approval by institutional ethics committee, starting January 2016, 200 consecutive invasive breast carcinoma patients (mean age 51.2 years, all palpable breast masses) undergoing diagnostic breast imaging had their DM and DBT reviewed by two radiologists independently, who were blinded of the cyto/histology and the original DM and DBT reporting. Of these, 47 patients who were treated with NACT and had pre- and post-NACT DM and DBT were recruited. After a core-biopsy, radio-opaque marker(s) were placed in tumor core/margin. The pre- and post-NACT DM and DBT findings were compared and correlated with the extent of response of the primary breast tumor to NACT. DM and DBT characteristics predictive of (in-breast) pCR of index breast lesion were identified.

Results: Of the 47 patients who underwent NACT, 44 received both anthracycline and taxane, and 3 received only an anthracycline based combination chemotherapy. Twelve patients underwent breast conservative surgery and the remaining underwent mastectomy. pCR was seen in 17 (36.2%) patients based on the surgical specimen histology. On clinical examination, 19 (40.4%) patients had clinical complete response (cCR) of the breast tumor, 11 (64.7%) of whom had pCR as well. Five patients had radiological complete response (rCR, no breast lesion visualised on post-NACT imaging)- 2 patients on DM alone, 2 patients on DBT alone, and one patient on both DM and DBT. Radio-opaque clips had some obscuring effects in 3 of these 5 patients, especially on DBT, in form of reduced visibility of breast lesion on DBT, c.w. corresponding DM images. All 5 patients with rCR had pCR (sensitivity=29.4%, specificity=100%), in contrast to only 11 (57.9%) patients with cCR having pCR. Patients with pCR had benign appearing (forced Bi-RADS 2 and 3) lesions on mammography more commonly on DM (p&lt;0.001) than on DBT (p=0.042) (41.2% vs 23.5%). Post NACT lesion morphology varied significantly between patients with and without pCR on DM (p=0.038) but not on DBT (p=0.182). Pre-NACT forced Bi-RADS score, lesion morphology or margin characteristics on DM and DBT did not vary significantly amongst patients with and without pCR.

Conclusions: Post-NACT DM and DBT features can predict pCR with high specificity but with low sensitivity. Pre-NACT DM and DBT features did not reliably predict response to NACT, and pCR in this study. DM may be better than DBT for assessing response to NACT in the presence of radio-opaque markers/clips.

Citation Format: Agarwal G, Sonthineni C, Mohindra N, Jain N, Neyaz Z, Agrawal V, Krishnani N, Maylivahnan S, Mishra A, Lal P. Predicting pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) based on pre- and post-NACT digital mammography and digital breast tomosynthesis findings [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-11.

Symptom association probability does not reliably distinguish functional heartburn from reflux hypersensitivity

BACKGROUND

Symptom association probability (SAP) is thought to distinguish reflux hypersensitivity from functional disorders. A diagnosis of hypersensitive oesophagus (SAP-positive) indicates that gastro-oesophageal reflux disease (GERD) is the cause of continued symptoms.

AIM

To conduct an analysis of pH and symptom criteria that lead to a diagnosis of SAP-positivity METHODS: We calculated SAP for 205 patients with GERD symptoms refractory to proton pump inhibitor (PPI) therapy who underwent endoscopy with wireless pH monitoring from 2007 to 2014. Patients were divided into three groups: pH-negative with no oesophagitis (n = 45), pH-positive with no oesophagitis (n = 130), and patients with oesophagitis (n = 30). We constructed a 2 × 2 table of symptom and reflux event association and quantified the number of 2-minute intervals for each of the 2 × 2 variables that distinguished SAP-positive from SAP-negative. In a separate cohort of 58 patients who had undergone anti-reflux surgery, we evaluated the effects of pre-surgery SAP.

RESULTS

The difference in symptom association parameters that led to a diagnosis of an SAP-positive was small (2.98% in oesophagitis-positive; 1.56% in oesophagitis-negative/pH-positive; 0.48% in oesophagitis-negative/pH-negative). In the pH-negative/oesophagitis-negative group, a difference of 0.48% led to a diagnosis of hypersensitivity. There was significant variability in SAP values between day 1 and day 2 of pH testing in all groups, with the greatest in the oesophagitis-positive group, despite objective evidence for reflux (27% in oesophagitis-positive, 19% pH-positive/oesophagitis-negative, and 7% in pH-negative/oesophagitis-negative). Pre-surgery SAP was not associated with response to anti-reflux surgery.

CONCLUSION

In PPI-refractory GERD, SAP cannot accurately distinguish reflux hypersensitivity from functional oesophageal symptoms.

Abstract P1-11-07: Frozen section histology evaluation of surgical margins helps perform single step oncologically safe and cost-effective breast conservation surgery

This abstract was withdrawn by the authors.

Laparoscopic TEP repair of inguinal hernia does not alter testicular perfusion

PURPOSE

The effect of laparoscopic TEP repair on testicular perfusion is unclear. The procedure entails dissection of testicular blood vessels off the hernial sac and incorporation of a prosthetic mesh. This carries at minimum, a theoretical risk of compromise in testicular blood supply, which in turn may affect fertility. Our study aims to establish if any alteration in testicular perfusion occurs in very early (24 h), early (1 week) or late postoperative period (3 months) after laparoscopic TEP repair in the Indian population.

METHODS

In our prospective trial, 20 patients underwent unilateral and 8 underwent bilateral laparoscopic TEP hernia repairs using standard technique by experienced surgeons. Flow parameters of testicular, capsular and intratesticular artery were noted using color Doppler ultrasound preoperatively and postoperatively and the postoperative resistive indexes of operated side (n = 36) were compared with preoperative values. Additionally, for unilateral repairs, flow parameters on operated side were compared with the non-operated side.

RESULTS

No statistically significant difference was noticed in the resistive index of the arteries upon comparing these postoperative with preoperative values. For unilateral repairs, the flow parameters of the operated side were comparable with that of non-operated side (i.e. p > 0.05).

CONCLUSION

Laparoscopic TEP performed by experienced surgeons does not alter testicular flow dynamics in early or late postoperative period.

Abstract P6-13-08: Palbociclib and paclitaxel on an alternating schedule for advanced breast cancer: Results of a phase Ib trial

Background: Palbociclib (P) is an oral CDK 4/6 inhibitor (CDKi) that was recently FDA approved in combination with endocrine therapy for metastatic breast cancer. We have performed a Phase I trial of P in combination with paclitaxel (T) based on preclinical studies suggesting that P synergizes with T when given on an alternating schedule, enabling cell cycle synchronization in tumor cells. We now present the dose expansion cohort.

Methods: Patients (Pts) enrolled on the trial had Rb-expressing tumors of any estrogen/progesterone/HER2 receptor type, adequate organ function, and ≤3 prior chemotherapy regimens for metastatic breast cancer (mBC). Prior adjuvant or metastatic taxane was allowed. Dose escalation led to expansion at P100mg or 75mg, starting with 3 days of P (run-in) and reduction of P dosing from 5-day to 3-day intervals (days 2-4, 9-11, 16-18 of each 28 day cycle). T at 80mg/m2 was given weekly for 3 cycles; thereafter, T was administered days 1, 8 and 15 of 28 day cycle. Weekly toxicity assessments were performed; RECIST 1.0 response was assessed every 2 cycles as partial response (PR), stable disease (SD) or progressive disease (PD). Pts had the option to discontinue T and continue on P alone (3 on/1 off schedule) if they attained SD after cycle 6.

Results: 27 pts enrolled on study (15- dose escalation, 12- dose expansion). Results are shown in the Table. 21 pts had received prior taxane; pts had received a median of 2 chemotherapy regimens for mBC. DLTs were grade 3 AST/ALT (n=1, at 125 mg) and febrile neutropenia (FN) (n=1, at 100 mg). Uncomplicated grade 3/4 NTP was common and frequently led to dose reduction or dose interruption during the first cycle of therapy. Frequency of NTP did not change with reducing the days of P. Among 24 evaluable patients, 14 (58%), had PR or SD ≥ 6 months across all dose levels. Of 14 pts who responded, 10 (71%) had received prior taxane. 20 pts are off study; 19 for PD, and 2 for toxicity (NTP in cycle 17 and FN in cycle 1); 7 pts remain on study. Prolonged tumor responses were seen.

Conclusions: P and T can be safely combined on an alternating dosing schedule; the optimal combination dose is 75 mg of P and 80mg/m2 of weekly T. The high response rate warrants a randomized trial to determine the incremental benefit over T alone. Additional mechanistic studies are in progress to understand the in vivo effects of the alternating dosing schedule on cell cycle activity and tumor proliferation.

Starting Dose Level P (mg)Number (Total 27)DLTGrade 3/4 NTP (n)Final Dose P mg (n)Dose Interruption (n)Best Response (n)5030050 (1) 50 (1) 50 (1)No (2) Yes (1)PR (1) SD (1) PD (1)7530275 (1) 50 (1) 25 (1)No (1) Yes (2)PR (2) SD (1)100605100 (2) 75 (3) 25 (1)No (1) Yes (5)PR (2) SD (1) PD (3)12531- LFT375 (1) 50 (2)No (0) Yes (3)PR (1) SD (2)75 (Run-In)60175 (5) 50 (1)No (4) Yes (2)PR (1) SD (2) PD (1) N/A (2)*100 (Run-In)61- FN5100 (1) 75 (4) 25(1)No (1) Yes (5)PR (4) SD (1) N/A (1)^*2 pts not yet evaluable. ^1 pt went off study due to FN after cycle 1.

Citation Format: Clark AS, O'Dwyer P, Troxel A, Lal P, Feldman M, Gallagher M, Driscoll A, Colameco C, Lewis D, Rosen M, Matro J, Bradbury A, Domchek S, Fox K, DeMichele A. Palbociclib and paclitaxel on an alternating schedule for advanced breast cancer: Results of a phase Ib trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-08.

Abstract P3-01-06: Sentinel lymph node biopsy after NACT: Results of a validation study in large/locally advanced breast cancer patients

Background:

Sentinel lymph node biopsy (SLNB) is the current standard of care for surgical staging of clinically node negative axilla (N0) early breast cancer patients undergoing primary surgery. SLN- identification rate (IR) of 90% and SLN- false negative rate (FNR) of 10% are considered minimum acceptable indices for SLNB. Its role in staging axillae in patients undergoing post-NACT surgery is somewhat unclear. In India, and most low-and-middle income countries, large operable breast cancers (LOBC) and locally advanced breast cancers (LABC) constitute a large proportion of breast cancer patients treated. These patients are usually are treated with NACT, followed by surgery and radiation therapy. In a prospective validation SLNB study, we investigated the accuracy of SLNB in staging post-NACT N0 axilla in a patient cohort that were LOBC or LABC at the time of initial presentation.

Methods:

Hundred consenting non-inflammatory LOBC/LABC patients (mean age 49.3+8.6; index stage T3,N0-1=21; T4b,N0-1=33; T1-3,N2a=24; T4b,N2a=22) who were N0 after NACT at time of surgery (Breast conservation surgery in 19, Mastectomy in 81) were included. Majority had Infiltrating ductal carcinoma (n=87), and grade II/III tumors (n=93); 45 were hormone receptor positive (+), 29 had HR negative (-) HER2(+); and 26 had triple negative breast cancer on IHC sub-typing. Commonest NACT regimen used was Anthracycline followed by taxanes in 83. SLNB was performed using low-cost methylene-blue and 99mTc-Antimony-colloid, which were produced in-house using well standardized protocols, with clearance of the institutional ethics committee. Irrespective of the SLN histology, a complete axillary dissection (ALND) was carried out in all. SLN-IR and SLN-FNR were calculated, comparing the histological status of the SLN and the ALND specimen. Factors predicting non-identified SLN and false negative SLN were evaluated in uni-variate and multi-variate analysis.

Results:

With a combination of methylene blue dye and radiopharmaceutical, the SLN-IR was 81%. Mean number of SLN removed was 2.4+/-1.02. Mean number of nodes removed at ALND was 13.3+/-2.2. SLN-IR varied significantly (p&lt;0.05) per index stage, and were- 90.4% in T3,N0-1; 84.4% in T4b,N0-1; 83.3% in T1-3,N2a; and 63.6% in T4bN2a. The FNR was 17.3% for the whole cohort. FNR varied significantly (p&lt;0.05) per index stage, and were- 8.3% in T3,N0-1; 14.9% in T4b,N0-1; 22.2% in T1-3,N2a; and 30% in T4bN2a. Factors found predictive of non-identified SLN were tumor stage T4b, nodal stage N2a, extra-nodal spread, and LVI. Factors found predictive of FNR SLN were tumor stage T4b, nodal stage N2a, and extra-nodal spread.

Conclusions:

Considering SLN-IR of 90% and SLN-FNR of 10% as acceptable standards, SLNB in post-NACT N0 patients undergoing surgery was not found robust in staging the axilla, with the exception of patients with index stage T3,N0-1 who had SLN-IR of 90.4% and SLN-FNR of 8.3%. Patients with (pre-NACT) skin involvement(T4b), matted axillary nodes(N2a) and LVI are fraught with high-risk of non-identification and false-negative SLNB.

Citation Format: Agarwal G, Gambhir S, Lal P, Rajan S, Krishnani N, Mishra A, SabaRetnam M, Agarwal A, Chand G, Verma AK, Mishra SK, Kumari N, Agrawal V, Kheruka SC. Sentinel lymph node biopsy after NACT: Results of a validation study in large/locally advanced breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-06.

Promoting operational research through fellowships: a case study from the South-East Asia Union Office

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.