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Phthalates are known endocrine-disrupting chemicals used indiscriminately as constituents in consumer products including food processing, and packaging, cosmetics, personal care and household items. Although, few studies have assessed the risk of breast cancer on exposure to phthalates, their association with breast cancer risk in Indian women have not yet been evaluated.We conducted a case-control study involving 171 participants. Urinary concentrations of six phthalate dieters; DMP (Dimethyl phthalate), DEP (Diethyl phthalate), DBP (Dibutyl phthalate), BBP (benzyl butyl phthalate), DEHP (Di-2-ethyl-hexyl phthalate), DINOP (Di-n-octyl phthalate) were estimated by GC-MS and geometric means were calculated. Univariate and multivariable logistic regression was performed to assess breast cancer risk on exposure to phthalates. Genes responsive to phthalates were identified through literature search and matched with NGS data, and gene-enrichment analysis was performed.Significant associations were observed between urinary phthalate concentrations and increased risk of breast cancer for di-butyl phthalate (OR=1.5, 95% CI; 1.06, 2.11, p = 0.002) and di-2-ethyl-hexyl phthalate (median vs ≤ median; OR=2.97, 95% CI; 1.18, 7.47, p = 0.005) in multivariable analyses. We also found several phthalate-responsive gene mutations in paired breast tumor tissues, which include PTPRD (76.19%), AR (42.86%), CYP1A1 (42.86%), CYP19A1 (23.81%), AHRR (19.05%), PIK3CA (19.05%), CYP1B1 (9.52%), RB1 (9.52%) and MMP9 (9.52%). Gene-enrichment analysis revealed that these genes form a major part of ER/PR, PPAR and HIF-1α-TGF-β signaling cascades involved in breast cancer CONCLUSION: Although the sample size is small, in this first case-control study from India, DBP and DEHP were found to be associated with increased risk of invasive breast cancer and tumor tissues revealed mutations in several phthalate-responsive genes. It is, therefore suggested that human biomonitoring in India and larger studies evaluating the early life genetic and epigenetic alterations on phthalates exposure are required to establish their role in breast carcinogenesis.

Among percutaneous biopsy techniques, the vacuum assisted breast biopsy (VAB) obtains large tissue samples to alleviate some of the limitations associated with conventional percutaneous biopsy techniques. We aimed to determine the efficacy of VAB in previous equivocal biopsies using the mammotome device.A prospective non-randomized efficacy study was planned and executed on 43 patients (42 women, 1 man) whose previous FNAC and/or CNB of breast masses yielded inconclusive results or were suspicious for cancer.VAB revealed malignancy in 31 (72%) of the 43 patients. Among them, 23 were diagnosed as infiltrative ductal carcinoma (IDC) on VAB, 20 underwent surgery and the final histopathological diagnosis was the same in 19 of them. One patient showed ductal carcinoma-in-situ (DCIS) only in the surgical specimen. Other malignancies included infiltrating lobular carcinoma (ILC) in 5 patients and one each of DCIS, non- Hodgkin lymphoma (NHL) and metastasis from lung cancer. Benign lesions were detected in 12 (28%) patients. These included 8 fibroadenomas, 2 fibrocystic disease and 1 each of mastitis and breast abscess. Four patients with fibroadenoma underwent surgical excision.

Data on patients with localized Ewing sarcoma family of tumors (ESFT) who have received a uniform chemotherapy protocol are minimal.This is a single institutional review of patients with ESFT treated between June 2003 and November 2011.224/374 (60%) patients with ESFT presented with localized disease; median age was 15 years (range: 0.1-55). Ninety-nine patients underwent surgery of which 50 received adjuvant radiotherapy; 80 patients received radical radiotherapy following neoadjuvant chemotherapy. At median follow-up of 40.2 months (range: 1.3-129), 5-year EFS, OS, and local-control-rate, were 36.8 ± 3.6%, 52.4 ± 4.3%, and 63 ± 4.3%, respectively. In multivariate analysis, tumor diameter8 cm (P = 0.03), symptom duration4 months (P = 0.04), and WBC11 × 10(9) /L (P = 0.003) predicted inferior EFS; spine/abdomino-pelvic primary (P = 0.009) and WBC11 × 10(9) /L (P = 0.003) predicted inferior OS. Tumor size8 cm (P = 0.03) and radical radiotherapy as local treatment (P = 0.01) predicted inferior local-control-rate.Prognostic hazard models for EFS and OS based on significant prognostic factors suggested that patients with combination of ESFT of spine/abdomino-pelvic region and baseline WBC11 × 10(9) /L had inferior OS (hazard ratio 4.44, P0.001) while patients with combination of ESFT with symptom duration4 months, tumor diameter8 m and baseline WBC11 × 10(9) /L had inferior EFS (hazard ratio 3.89, P = 0.002).

Data on extraosseous Ewing sarcoma (EES) with uniform chemotherapy protocol are minimal. We aimed to examine this aspect in our patients, identify prognostic factors and compare the same with osseous Ewing sarcoma.A single institutional data review of patients with EES treated between June 2003 and November 2011 with uniform chemotherapy and evaluated on intent-to-treat analysis was done.Of 374 patients with Ewing sarcoma, 60 (16%) were EES with median age 16 years; 20 (33%) had metastases. After median follow-up of 25 months (range: 1.7-104.4), 5-year event free survival (EFS), OS, and local-control-rate were 47.1 ± 7.9%, 61.6 ± 7.8%, and 77.9 ± 8.6%, respectively for entire EES cohort. In multivariate analysis, hemoglobin ≤ 10 g/dl (P = 0.03), and white blood cell count (WBC)11 × 10(9) /L (P = 0.009) predicted inferior EFS for the entire EES cohort. Low hemoglobin (P = 0.05) and high LDH (P = 0.01) predicted inferior OS for the entire EES cohort on multivariate analysis. As compared to the cohort of skeletal primary (n = 314), higher proportion of patients underwent surgery in the cohort of EES (P = .003); EFS (P = 0.004) and OS (P = 0.08) were superior for patients with EES than patients with skeletal Ewing sarcoma.These data of EES suggests that low hemoglobin and high WBC count adversely affect EFS. Overall outcome was significantly better for EES than skeletal primary tumors.

Breast cancer is the commonest cancer among women worldwide. Surgery plays an important role in its management. Axillary lymph node dissection has been the standard of care for staging, prognostication and control of axillary disease for almost a century. However, this time-tested paradigm is shifting gradually in the western world, because of the increasing use of screening mammography resulting in the detection of a large proportion of node-negative early breast cancers and a significant incidence of axillary lymph node dissection-related arm morbidity. Minimally invasive and less morbid procedures such as sentinel lymph node biopsy are being used more commonly in the West. However, the western experience cannot be directly extrapolated to the Indian scenario because of the differences in patient profile, treatment standards and expertise available. There is a need to critically analyse these issues before the Indian medical community advocates sentinel lymph node biopsy as a routine procedure for managing patients with breast cancer.

Breast conservation therapy is a well-established treatment modality for early breast cancer. It is not widely practised in developing countries because of a lack of awareness and treatment facilities, and physician and patient bias. We analysed our experience of breast conservation therapy.We retrospectively reviewed 102 patients who had undergone breast conservation surgery and axillary dissection for breast cancer. Surgery was followed by 45 Gy of radiation to the whole breast and 15-20 Gy of tumour bed boost. All high risk patients received adjuvant systemic therapy. The disease profile, morbidity and treatment outcome were analysed.Out of 902 patients, 102 underwent breast conservation therapy (90 had early breast cancer and 12 had locally advanced breast cancer). Only 19.6% of patients with early breast cancer received breast conservation therapy. One-third of the patients had had a prior surgical intervention. The mean tumour size was 2.8 cm, 44% had nodal involvement and 29% were oestrogen- and progesterone-receptor negative. At a mean follow up of 32 months, only 1 patient had local recurrence, and the 5-year projected disease-free and overall survival were 82% and 88%, respectively.Breast conservation therapy should be offered to suitable breast cancer patients. Strict adherence to protocol-based therapy and active multidisciplinary coordination are crucial for a successful breast conservation therapy programme. Education of the patient as well as the physician population is necessary for increasing the breast conservation therapy rates in India.

Early detection and multimodality therapy has resulted in an overall improvement of survival among breast cancer patients. Despite a significant shift in the treatment approach from radical mastectomy to breast conservation a significant number of patients develop lymphedema. This study was conducted to evaluate the prevalence and risk factors for development of lymphedema.Retrospective analysis for prevalence of lymphedema in a tertiary care regional cancer centre.Three hundred treated breast cancer patients with a minimum follow up of one year were evaluated for the prevalence and risk factors for lymphedema. Lymphedema was assessed using a serial circumferential measurement method. More than 3 cm difference in circumference is considered as clinical significant lymphedema. Univariate and multivariate analysis were performed for evaluating the risk factors by using the Chi square test and Cox logistic regression analysis.The prevalence of clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema. The prevalence of lymphedema was 13.4 % in patients treated with surgery only where as the prevalence was 42.4% in patients treated with surgery and radiotherapy. Stage of the disease, body surface area1. 5 m2, presence of co-morbid conditions, post operative radiotherapy and anthracycline based chemotherapy were significant risk factors in univariate analysis where as axillary irradiation and presence of co-morbid conditions have emerged as independent risk factors in multivariate analysis (P0.001).Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Presence of co-morbid conditions and axillary radiation significantly increases the risk of lymphedema. A combination of axillary dissection and axillary radiation should be avoided whenever feasible to avoid lymphedema.

Isolated ipsilateral supraclavicular lymph nodal (IISCLN) metastasis was considered part of locally advanced breast cancer (LABC) previously but the recent staging system categorised this group to metastatic disease (stage IV). There is no clear consensus on intent of therapy in patients with IISCLN. A retrospective comparative analysis of IISCLN and LABC patients treated with a curative multimodality approach was performed to evolve guidelines on treatment approach in patients with IISCLN spread.A total number of 670 patients with breast cancer treated in the Department of Surgical Oncology, IRCH, AIIMS, during the period between January, 1993 to December, 2000 were studied retrospectively. Out of these 16 (2.4%) patients with cytology proven isolated metastasis to ipsilateral SCLN without any other distant disease and 299 LABC patients were analysed. All patients received neoadjuvant anthracycline based chemotherapy, surgery, postoperative radiotherapy (50 Gy) including supraclavicular fossa. The relapse patterns and survival in both the groups were compared.At a median follow up of 36 months (range 9-72 months) the total recurrence in the IISCLN group was 31% and in the LABC group was 26%, the systemic recurrence was equal at 25% in each group while the locoregional recurrence was 12% and 7% in the IISCLN and LABC groups respectively. The overall survival (OS) was 81% and 91% whereas the disease-free survival (DFS) was 12% and 7% in the IISCLN and LABC groups, respectively.Intent of therapy in metastatic breast cancer is palliative. However, patients with IISCLN metastasis have a relatively less aggressive biologic behaviour as compared to patients with spread to other distant sites. Results of the current study shows that the relapse patterns and survival of IISCLN group and LABC are comparable. Hence, despite being staged as metastatic disease, patients with IISCLN spread should be treated with combined modality approach for prolonged survival.

Adenocarcinoma of the stomach is usually advanced at presentation, and local or distant spread may preclude the option of primary curative resection. Neoadjuvant chemotherapy (NAC) has shown promise in downstaging initially unresectable disease. This pilot study was planned to assess the utility of NAC using Cisplatin and 5-Fluoro uracil in the management of initially unresectable gastric cancer.Ten patients with unresectable gastric adnocarcinoma were included. They received two cycles of cisplatin, 30 mg/m2 intravenously in combination with 5-Fluoro Uracil, 1000 mg/m2. They were restaged using Endoscopy and CT scan and taken up for exploratory laparotomy.Eight of 10 patients (80%) had an objective response to chemotherapy. Six patients (60%) with initially unresectable disease could be offered curative surgery. The median survival was 10 months (range 1-60 months). There were two long term survivors (48 and 60 months respectively).Neoadjuvant chemotherapy (NAC) is an effective option in downstaging initially unresectable gastric carcinoma. Complete response to chemotherapy also predicts long term survival.

The harmonic scalpel is recently emerging as an alternative surgical tool for dissection and haemostasis and has been extensively used in the field of minimally invasive surgery. We studied the utility and advantages of this instrument over electrocautery for performing modified radical mastectomy.The operative and morbidity details of twenty-three breast cancer patients who underwent modified radical mastectomy using the harmonic scalpel were compared with 23 matched controls operated with electrocautery by the same surgical team.There was no significant difference in the operating time between the harmonic scalpel and electrocautery group (104 and 100 mins, p0.05). The blood loss (60 +/- 35 ml and 294 +/- 155, p0.001) and drainage volume (590 +/- 430 ml and 1,085 +/- 690 ml, p0.001) were significantly lower in the harmonic scalpel group. There was a significant reduction of drain days in harmonic scalpel group (mean five and nine days, p0.05). There was no significant difference in the seroma rate between two groups (16% and 22%).Modified radical mastectomy using harmonic scalpel is feasible and learning curve is short. Harmonic scalpel significantly reduces the blood loss and duration of drainage as compared to electrocautery.

Venous access is crucial for cancer management for administration of drugs blood products, antibiotics and periodic sampling.To review our experience of long-term venous access devices used over a ten-year period and to analyse the outcome in cancer patients in Indian setting.A retrospective analysis of data in a tertiary care Regional cancer centre.A total of 110 patients with various malignancies requiring long-term venous access were included in the study. A uniform open cut down procedure under local anaesthesia was used and silastic Hickman catheters were inserted in the cephalic or external jugular or internal jugular veins. A record of all complications and catheter loss and final out come were analysed.A total of 111 catheters were used in 110 patients. Sixty-nine catheters were placed in cephalic, 40 in external jugular, and 2 in internal jugular vein. Duration of catheter indwelling period ranged from 7 to 365 days with a median of 120 days. In 90% of the cases the catheter tip was located either in superior vena cava or in right atrium. Total catheter related complications were observed in 37 (34.54%) patients and catheter loss rate due to complications was 15.4% (17/111).Long-term venous access using Hickman catheter insertion by open cut down method is a simple, safe and reliable method for administration of chemotherapeutic agents, antibiotics and blood products. The incidence of various complications and catheter loss was acceptable and overall patient satisfaction was good.