Breast Cancer in Young Women from a Low Risk Population in Nepal

Thapa, Bibhusal,Singh, Yogendra,Sayami, Prakash,Shrestha, Uttam Krishna,Sapkota, Ranjan,Sayami, Gita Asian Pacific Journal of Cancer Prevention 2013 Asian Pacific journal of cancer prevention Vol.14 No.9

Background: The overall incidence of breast cancer in South Asian countries, including Nepal, is low compared to Western countries. However, the incidence of breast cancer among young women is relatively high. Breast cancer in such cases is characterized by a relatively unfavorable prognosis and unusual pathological features. The aim of this study was to investigate clinico-pathological and biological characteristics in younger breast cancer patients (<40 years) and compare these with their older counterparts. Materials and Methods: Nine hundred and forty four consecutive female breast cancer patients, admitted to the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal between November 1997 and October 2012, were retrospectively analyzed. Results: Out of the 944 female breast cancer patients, 263 (27.9%) were <40 years. The mean age was $34.6{\pm}5.0$ years among younger patients compared to $54.1{\pm}9.9$ for those ${\geq}40$ years. The mean age at menarche was also significantly lower ($13.5{\pm}1.5$ vs $14.2{\pm}1.5$ years p=0.001) while the mean duration of symptoms was significantly longer (7.6 vs 6.5 months p=0.004). Family history of breast cancer was evident in 3.0% of the young women versus 0.3% in the older one. Mammography was performed less frequently in younger patients (59.7%), compared to older (74.4%), and was of diagnostic benefit in only 20% of younger patients compared to 85% of older ones. At diagnosis, the mean tumor diameter was significantly larger in young women ($5.0{\pm}2.5$ vs $4.5{\pm}2.4cm$, p=0.005). Axillary lymph nodes were positive in 73% of younger patients and 59% of older patients. In the younger group, the proportion of stage III or IV disease was higher (55.1% vs 47.1%, $p{\leq}0.05$). The proportion of breast conserving surgery was higher in young patients (25.1% vs 8.7%) and a higher proportion of younger patients receive neoadjuvant chemotherapy (9.9% vs 2.8%). The most common histological type was ductal carcinoma (93.1% vs 86%). The proportion of histological grade II or III was higher in younger patients (55.9% vs 24.5%). Similarly, in the younger group, lymphatic and vascular invasion was more common (63.2% vs 34.3% and 39.8% vs 25.4%, respectively). Patients in the younger age group exhibited lower estrogen and/or progesterone receptor positivity (34.7% vs 49.8%). Although statistically not significant, the proportion of triple negative tumors in younger age group was higher (22.4% vs 13.6%). Conclusions: Breast cancer in young Nepalese women represents over one quarter of all female breast cancers, many being diagnosed at an advanced stage. Tumors in young women exhibit more aggressive biological features. Hence, breast cancer in young women is worth special attention for earlier detection.

Low Lung Cancer Resection Rates in a Tertiary Level Thoracic Center in Nepal - Where Lies Our Problem?

Thapa, Bibhusal,Sayami, Prakash Asian Pacific Journal of Cancer Prevention 2014 Asian Pacific journal of cancer prevention Vol.15 No.1

Background: Resection rates of lung cancer are low in general and especially in countries like Nepal. Advanced stage at presentation and poor general condition of the patient are the usual causes. Materials and Methods: In this prospective observational study, one hundred cases of lung cancer who presented at the Thoracic Surgery Unit between October 2011 and October 2012 were included. Results: Those aged in the $6^{th}$ and $7^{th}$ decades together accounted for 72/100 patients. The male to female ratio was 2:1. There was a mean-$29.2{\pm}14.2$ pack yrs smoking history with only five non-smokers. Seventy-six patients presented with locally advanced disease while 21 had metastases. Only three had local disease. The average time between onset of symptoms to first contact with a doctor was $2.3{\pm}5.3$ months (range: 0-35.6 months). Average time between first contact to referral was $50.4{\pm}65.7$ days (range-0-365). Only three patients were resected, one after neo-adjuvant chemotherapy. Advanced disease was the cause of unresectability in 95 cases. One of three patients with local disease had pulmonary functions allowing the warranted resection. $N_2$ disease with $T_{1-3}$ on CT scan was found in 47. Three of these patients underwent mediastinoscopy and all confirmed uninvolved $N_2$. Conclusions: Lung resection rates in our center remain low. Late presentation leading to advanced disease and poor pulmonary reserves preclude resection in most cases. More liberal use of mediastinal staging and better assessment of pulmonary functions may allow us to improve resection rates.

Tumor-like Presentation of Tubercular Brain Abscess: Case Report

Dan B. Karki,Ghanashyam Gurung,Mohan R. Sharma,Ram K. Shrestha,Gita Sayami,Gopal Sedain,Amina Shrestha,Ram K. Ghimire 대한자기공명의과학회 2015 Investigative Magnetic Resonance Imaging Vol.19 No.4

A 17-year-old girl presented with complaints of headache and decreasing vision ofone month’s duration, without any history of fever, weight loss, or any evidence ofan immuno-compromised state. Her neurological examination was normal, exceptfor papilledema. Laboratory investigations were within normal limits, except for aslightly increased Erythrocyte Sedimentation Rate (ESR). Non-contrast computerizedtomography of her head revealed complex mass in left frontal lobe with a concentric,slightly hyperdense, thickened wall, and moderate perilesional edema with masseffect. Differential diagnoses considered in this case were pilocytic astrocytoma,metastasis and abscess. Magnetic resonance imaging (MRI) obtained in 3.0 Tesla(3.0T) scanner revealed a lobulated outline cystic mass in the left frontal lobe withtwo concentric layers of T2 hypointense wall, with T2 hyperintensity between theconcentric ring. Moderate perilesional edema and mass effect were seen. Postgadolinium study showed a markedly enhancing irregular wall with some enhancingnodular solid component. No restricted diffusion was seen in this mass in diffusionweighted imaging (DWI). Magnetic resonance spectroscopy (MRS) showed increasedlactate and lipid peaks in the central part of this mass, although some areas at thewall and perilesional T2 hyperintensity showed an increased choline peak withoutsignificant decrease in N-acetylaspartate (NAA) level. Arterial spin labelling (ASL) anddynamic susceptibility contrast (DSC) enhanced perfusion study showed decrease inrelative cerebral blood volume at this region. These features in MRI were suggestiveof brain abscess. The patient underwent craniotomy with excision of a grayishnodular lesion. Abundant acid fast bacilli (AFB) in acid fast staining, and epithelioidcell granulomas, caseation necrosis and Langhans giant cells in histopathology, wereconclusive of tubercular abscess. Tubercular brain abscess is a rare manifestationthat simulates malignancy and cause diagnostic dilemma. MRI along with MRS andmagnetic resonance perfusion studies, are powerful tools to differentiate lesions insuch equivocal cases.

Tumor-like Presentation of Tubercular Brain Abscess: Case Report

Karki, Dan B.,Gurung, Ghanashyam,Sharma, Mohan R.,Shrestha, Ram K.,Sayami, Gita,Sedain, Gopal,Shrestha, Amina,Ghimire, Ram K. Korean Society of Magnetic Resonance in Medicine 2015 Investigative Magnetic Resonance Imaging Vol.19 No.4

A 17-year-old girl presented with complaints of headache and decreasing vision of one month's duration, without any history of fever, weight loss, or any evidence of an immuno-compromised state. Her neurological examination was normal, except for papilledema. Laboratory investigations were within normal limits, except for a slightly increased Erythrocyte Sedimentation Rate (ESR). Non-contrast computerized tomography of her head revealed complex mass in left frontal lobe with a concentric, slightly hyperdense, thickened wall, and moderate perilesional edema with mass effect. Differential diagnoses considered in this case were pilocytic astrocytoma, metastasis and abscess. Magnetic resonance imaging (MRI) obtained in 3.0 Tesla (3.0T) scanner revealed a lobulated outline cystic mass in the left frontal lobe with two concentric layers of T2 hypointense wall, with T2 hyperintensity between the concentric ring. Moderate perilesional edema and mass effect were seen. Post gadolinium study showed a markedly enhancing irregular wall with some enhancing nodular solid component. No restricted diffusion was seen in this mass in diffusion weighted imaging (DWI). Magnetic resonance spectroscopy (MRS) showed increased lactate and lipid peaks in the central part of this mass, although some areas at the wall and perilesional T2 hyperintensity showed an increased choline peak without significant decrease in N-acetylaspartate (NAA) level. Arterial spin labelling (ASL) and dynamic susceptibility contrast (DSC) enhanced perfusion study showed decrease in relative cerebral blood volume at this region. These features in MRI were suggestive of brain abscess. The patient underwent craniotomy with excision of a grayish nodular lesion. Abundant acid fast bacilli (AFB) in acid fast staining, and epithelioid cell granulomas, caseation necrosis and Langhans giant cells in histopathology, were conclusive of tubercular abscess. Tubercular brain abscess is a rare manifestation that simulates malignancy and cause diagnostic dilemma. MRI along with MRS and magnetic resonance perfusion studies, are powerful tools to differentiate lesions in such equivocal cases.