COVID-19 Impact on Newly Diagnosed Breast Cancers at Regional Cancer Centre, Thiruvananthapuram-An Audit.

Geethu Babu The coronavirus pandemic has created havoc in every aspect of life including cancer care and was declared a pandemic. This audit was conducted to study the impact of the pandemic on diagnosis and treatment of newly diagnosed breast cancer patients at a tertiary cancer center in South India. A total of 1,647 patients who registered at Regional Cancer Centre (RCC), Thiruvananthapuram, Kerala, India for breast cancer during the period April 1, 2020, to September 30, 2020 (COVID-19 period) as well as April 1, 2019, to September 30, 2019 (pre-COVID-19 period) were included in the study. Data regarding the geographic distribution, stage at presentation, time factors for reporting for care, diagnosis, and treatment, referral for care elsewhere were collected and analyzed. The study was approved by the Institutional Review Board. Means and ranges were calculated for continuous type variables, and numbers and percentages for categorical variables. To determine whether there were significant differences between the two groups, independent t -test was used for continuous variables and chi-square test for categorical type of variables. A notable reduction (36%) in newly diagnosed breast cancer patients was seen in 2020 when compared with 2019. There was a significant difference in the geographic distribution of patients in both cohorts ( p = 0.001) and a notable reduction in the number of patients reporting to RCC for treatment from the northern districts of Kerala (81%) and outside Kerala (89.5%). There was no significant difference in the time (in weeks) since symptom onset and reporting to hospital or the clinical stage at diagnosis between the groups. Also, coronavirus disease 2019 (COVID-19) did not seem to negatively impact time intervals between date of registration and pathological diagnosis or start of primary treatment. More patients received neoadjuvant systemic therapy during 2020 compared with 2019, and this difference was statistically significant ( p = 0.004). There was no difference in the type of surgery (breast-conserving surgery vs. modified radical mastectomy). The results demonstrate that COVID-19 did not appear to negatively impact the diagnosis and treatment of newly diagnosed breast cancer patients. However, this is largely attributable to the significantly less number of patients who registered, for whom the departments were able to maintain timely cancer care despite the difficult pandemic times. Significantly more patients received neoadjuvant systemic therapy in 2020.

Sacral Resections for Primary Sacral Tumor - an Experience from a Tertiary Care Cancer Center in India.

Primary sacral tumors are uncommon and sacrectomy is a complex surgical procedure with substantial risk of morbidity. We conducted a retrospective study of patients who had undergone sacral resections for primary sacral tumors between 2010 and 2020. Ten sacral resections including five type 1 sacrectomy (S1 resected), four type 2 (S1 spared), and one type 3 (S3 spared) were performed during the above period. The median age was 47 years and the most common histologic diagnosis was chordoma (50%). The median operating time was 705 min (range 180-960 min) with a median blood loss of 3400 ml (range 500-7000 ml) and a median duration of hospital stay of 13.5 days (range 7-68 days). All patients who underwent type 1 sacrectomy experienced major complications (Clavien-Dindo grade 3 or above) including one death in the immediate perioperative period. Microscopically positive margins (R1) were noted in two patients (20%). All patients with type 1 sacrectomy had R0 resection. The median follow-up period was 31 months. The median MSTS score was 12 (range 4-27). A total of seven patients (70%) had a minimum follow-up of 2 years without disease recurrence. Sacral resection for primary tumors of the sacrum with oncologically safe margins is feasible. Although associated with substantial perioperative morbidity, a detailed preoperative planning and execution of the surgery by a team of orthopedic oncosurgeon, surgical oncologist, and plastic surgeon offer a hope for survival in patients with acceptable functional outcome.

A Comparison Between Sequential Conventional and Hypofractionated Boost Following Whole-Breast Radiotherapy: A Propensity Score-Matched Analysis.

BACKGROUND: The majority of local relapses after breast conservation therapy occur in the proximity of the primary lesion. Studies have shown that boost radiotherapy (RT) following conventional whole-breast radiotherapy (WBRT) of 50 Gy in five weeks improves outcomes. Boost RT also increases the risk of moderate skin reactions and fibrosis. The ideal boost RT dose and timing (sequential versus simultaneous) after hypofractionated radiotherapy schedules remain unclear. This retrospective propensity score-matched analysis assessed the outcome of sequential hypofractionated boost compared to conventional fractionated boost. METHODS: The study was approved by the Institutional Review Board of the Regional Cancer Centre, Thiruvananthapuram, India. Patients with stage I-III breast cancer who have received adjuvant radiotherapy with a sequential boost of either hypofractionated RT (8 Gy in three fractions) or conventional fractionated RT (10 Gy in five fractions) after conservative breast surgery were identified from the radiotherapy planning records and included in this study. A 1:1 case matching was performed using a propensity score incorporating four known prognostic factors, namely, clinical and pathological composite stage, tumor grade, tumor biology (based on estrogen and/or progesterone and HER2 neu expression), and boost technique, which may have an impact on acute toxicity to make the two boost groups more homogenous. RESULTS: After propensity score matching (PSM), there were a total of 166 patients, with 83 patients each in both conventional and hypofractionated boost RT groups. The median follow-up period was 30.7 months. At two years, locoregional recurrence-free survival (LRFS) was 98.8% in both groups. Disease-free survival (DFS) at two years for the hypofractionated group and conventional group was 91.5% and 96.3% (hazard ratio (HR): 2.5, 95% confidence interval (CI): 0.664-9.4, p = 0.161), respectively, with no statistically significant difference. Patients with grade 3 tumors who received hypofractionated boost had a statistically significant increased risk of recurrence (DFS: 88.9% versus 100%, HR: 60.559, 95% CI: 0.138-26613.2, p = 0.011). The overall survival (OS) at two years was 100% in both groups. There was no difference in acute skin toxicity between the two groups. CONCLUSION: The present interim analysis shows similar locoregional recurrence-free survival, overall survival, and disease-free survival and acute skin toxicity for hypofractionated boost RT of 8 Gy in three fractions compared to the conventional boost of 10 Gy in five fractions. Hypofractionated boost is a feasible alternative option following hypofractionated whole-breast radiotherapy for women with breast conservation treatment. However, longer follow-up is required before forming definite conclusions.

Co-expression of galectin-3 and vimentin in triple negative breast cancer cells promotes tumor progression, metastasis and survival.

BACKGROUND: Lack of druggable targets and complex expression heterogeneity of known targets is common among TNBC subtypes. An enhanced expression of galectin-3 in TNBCs has already been documented. We have observed a tumor progression-dependent galectin-3 expression in TNBCs compared to adjacent epithelium and non TNBCs. OBJECTIVE: To unravel the association of galectin- 3 in tumor progression, aggressiveness and drug resistance in TNBC patients. METHODS: Galectin-3 expression in 489 breast cancer tissues was correlated with clinicopathological features and the results were validated in cell lines and mouse model by silencing galectin-3 using shRNA and the proteins were profiled by western blot and qRT-PCR. Protein interaction was analyzed by GFP Trap and Mass spectrometry. RESULTS: Galectin-3 expression correlated with tumor stage in TNBC and a lower galectin-3 expression was associated with poor patient survival. The positive correlation between galectin-3, vimentin and CD44 expression, pinpoints galectin-3 contribution to epithelial to mesenchymal transition, drug resistance and stemness. Vimentin was found as an interacting partner of galectin-3. Duplexing of galecin-3 and vimentin in patient samples revealed the presence of tumor cells co-expressing both galectin-3 and vimentin. In vitro studies also showed its role in tumor cell survival and metastatic potential, elementary for tumor progression. In vivo studies further confirmed its metastatic potential. CONCLUSIONS: Tumor progression dependent expression pattern of galectin 3 was found to indicate prognosis. Co-expression of galectin-3 and vimentin in tumor cells promotes tumor dissemination, survival and its metastatic capability in TNBCs.

Validation of Sentinel Lymph Node Biopsy Technique Using Dual Tracer Technique in Post Lumpectomy Early Breast Cancer Patients.

Sentinel lymph node biopsy (SLNB) is the gold standard for the evaluation of axilla in clinically node-negative early breast cancers. There is limited data on the role and efficacy of the same in the post lumpectomy scenario. This prospective interventional study was conducted over 1 year on 30 post lumpectomy pT1/2 cN0 patients. SLNB was performed by preoperative lymphoscintigram using technetium-labeled human serum albumin followed by intraoperative blue dye injection. Sentinel nodes were identified based on blue dye uptake and gamma probe and sent for intra operative frozen section. Completion axillary nodal dissection was performed in all cases. The primary end point was sentinel node identification rate and accuracy of nodal frozen section. Sentinel node identification rate was 86.7% (n = 26/30) for scintigraphy alone and 96.7% (n = 29/30) using combined method. Average sentinel nodal yield/patient was 3.6 (range 0-7). Maximum yield was seen for hot and blue nodes (1.86). Sensitivity (n = 9/9) and specificity (n = 19/19) of frozen section were 100% with a false negative rate of 0% (0/19). Demographic factors such as age, body mass index, laterality, quadrant, biology, grade, and pathological T stage had no impact on the identification rate. Sentinel lymph node using dual tracer has a high identification rate and a low false negative rate post lumpectomy. Age, body mass index, laterality, quadrant, grade, biology, and pathological T size had no impact on the identification rate.

YAP transduction drives triple-negative breast cancer aggressiveness through modulating the EGFR‒AKT axis in patient-derived xenograft cells.

Aside from the high prevalence of incidents of breast cancer, the high grade of heterogeneity and the dearth of standard treatment guidelines make triple-negative breast cancer (TNBC) the most refractory subtype. Though still in its infancy, the Hippo pathway has been known to play a critical role in tumorigenesis. However, the molecular mechanics through which the pathway exploits the breast cancer (BC) cell vulnerability are largely unexplored. In this study, we observed a relatively higher expression of the Hippo effector, yes-associated protein (YAP), in TNBC patients compared to non-TNBC patients. Thus, we sought to investigate the contribution of Hippo signaling in TNBC by focusing particularly on transducers of the pathway. Impeding YAP transactivation by means of RNA interference or pharmacological inhibition was carried out, followed by evaluation of the subsequent biological changes at the molecular level. We successfully translated the observed data into a TNBC patient-derived xenograft cell line (PDXC). We discovered that nuclear translocation of YAP was associated with TNBC aggressive characteristics and activated the EGFR-AKT axis. Here, we explored the putative role of the Hippo transducer in enhancing cancer hostility and observed that YAP transduction drives proliferation, migration, and survival of TNBC by preventing cellular apoptosis through mediating EGFR activation. These observations suggest that YAP represents a major vulnerability in TNBC cells that may be exploited therapeutically.

Immunohistochemical expression of PD-L1 and MDR1 in breast tumors: association with clinico-pathological parameters and treatment outcome.

Antitumor immune evasion is a hallmark for the development and progression of cancer. Tumor cells adopt various mechanisms to escape the host immune system recognition. One such mechanism is the over expression of programmed death ligand (PD-L1), a negative T cell regulatory molecule. Because PD-L1 overexpression causes resistance to chemotherapeutic response in many cancers, herein we explored the relationship between PD-L1 and multidrug resistance protein MDR1 in breast cancer. Immunohistochemical evaluation of PD-L1 and MDR1 proteins in 194 breast cancer tissue samples were carried out. The relationship between PD-L1 and MDR1 expression on cancer cells with clinicopathological factors and prognosis was investigated. IHC showed a significant correlation between PD-L1 and MDR1 expression on tumor cells. Increased PD-L1 expression was also associated with lymph node status and tumor grade of the patient. Our results also revealed that the expression of PD-L1 and MDR1 was higher in TNBC subtype compared to other breast cancer subtypes. Therefore, a better understanding of the molecular mechanism through which PD-1/PD-L1 pathway contribute to the chemoresistance might bring forth the prognostic significance of PD-L1 and selection of patients who may benefit from immunotherapy.

Effectiveness of triennial screening with clinical breast examination: 14-years follow-up outcomes of randomized clinical trial in Trivandrum, India.

BACKGROUND: This study presents the preliminary results of a randomized controlled trial (RCT) initiated in January 2006 in India to evaluate the effectiveness of clinical breast examination (CBE) in reducing breast cancer mortality as compared to a no-screening control group reported significant downstaging in the intervention group. The present manuscript reports long-term follow-up outcomes. METHODS: Women 30-69 years old from 133 intervention clusters and 141 control clusters were invited to participate. Women in the intervention arm underwent three rounds of CBE every 3 years. CBE-positive women were reexamined by a physician, and triple-assessment was performed on those confirmed to have abnormalities. All participants were followed through home visits and linkage with population-based cancer registry. RESULTS: Of the 55,843 eligible women in the intervention arm, 95.7% had CBE at least once and 11.5% were CBE-positive. Breast cancers were diagnosed in 335 participants in the intervention group and 273 in the control group (N = 59,447). Age-standardized incidence rate of early cancer was 30.4 of 100,000 in the intervention and 21.9 of 100,000 in the control group, with a rate ratio (RR) of 1.4 (95% confidence interval [CI], 1.1-1.8). The age-standardized breast cancer mortality rates were 11.3 and 11.1 per 100,000 in intervention and control arms, respectively (RR, 1.1; 95% CI, 0.8-1.5) after 15 years. Five-year breast cancer survival rates were 77.0% in the intervention and 71.2% in the control groups (overall p value = .043). CONCLUSIONS: Triennial CBE screening failed to demonstrate any mortality benefit despite achieving a shift toward earlier stage at detection and improved survival in the intervention arm. CBE is a valuable tool for diagnosis of breast cancer in symptomatic women especially in areas where mammography and/or breast cancer screening programs are not widely available.

Effects of Revision Surgery and Surgical Margins on Outcome of Peripheral Soft Tissue Sarcomas: Experience from a Tertiary Cancer Care Centre.

INTRODUCTION: The purpose of this study is to assess the impact of revision surgery, after unplanned excision, on oncological outcome and surgical morbidity in soft tissue sarcomas and also to assess the relation between margin status and oncologic outcome. MATERIALS AND METHODS: We undertook a retrospective analysis of prospectively maintained database of 153 patients with peripheral soft tissue sarcomas treated in our institute from 2006-2010. RESULTS: Postoperatively, 111(72.5%) patients had negative margins, 20(13.1%) had close margins and 22(14.4%) had planned positive margins. Local recurrence rate was 19.8% in patients with negative margins and 28.6% for patients with close or positive margins (p= 0.007). There was no statistically significant difference in rates of distant metastases (18.9% vs 21.4%, p value 0.56) and five-year overall survival (82.5% Vs 79.8%, p value 0.41) between margin negative and close/positive groups. The five-year overall survival rates were 80.4 vs 77.8% (p =0.42) and five-year disease-free survival rates were 72.4% vs 70.2% (p=0.3), in the revision surgery group and primary surgery group respectively. CONCLUSION: Margin status after excision of soft tissue sarcoma is not a direct predictor for overall survival or distant metastasis. Revision surgery after an unplanned excision does not carry worse survival compared to primary surgery group.

Design and Process of Implementation Mobile Application Based Modular Training on Early Detection of Cancers (M-OncoEd) for Primary Care Physicians in India.

BACKGROUND: Early detection of curable cancers is a cost-effective way to address the cancer care burden of low- and middle-income countries and active engagement of primary care physicians using mobile technology can have a significant impact on cancer outcomes in a short time. AIMS: To describe the process of mHealth study; Oncology Education and Training for Providers using Mobile Phones which developed a mobile application (M-OncoEd) to educate physicians on approaches to early detection of curable cancers. It also aims to describe how the insight gained through qualitative research by the researchers was used in the design and implementation of the project. METHODOLOGY: Qualitative research methods were used in all the phases of the study. Phenomenology was used in the formative phase with three expert meetings, two Focus Group Discussion (FGD) and five In-depth Interviews (IDI), and during the implementation stage with two FGDs, three IDI, and five informal discussions. OBSERVATIONS: The majority of curable cancers are detected at a late stage and poorly managed in India, and active engagement of primary care physicians can have a significant impact on cancer outcomes. There is a lack of knowledge and skills for early detection of cancers among consultants and physicians and this can be attributed to the training gap. M-OncoEd was a need-based well designed engaging learning platform to educate primary care physicians on Breast, Cervical, and Oral Cancer early detection. It was found to be very useful by the beneficiaries and made them more confident for early detection of cancers from the community. CONCLUSIONS: This research study could design a need-based, cost-effective mobile-based learning tool for primary care physicians using the expertise and experience of the experts in cancer care using qualitative methods.

Comparison of preoperative assessment tools in older patients undergoing cancer surgery: A prospective study.

INTRODUCTION: Surgery in older adults with cancer is complex due to multiple age related confounding factors. There are many scoring systems available for preoperative risk stratifications of older patients. Currently very few prospective studies comparing the various commonly used scales are available. This is the first study which compares the established preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS). MATERIAL AND METHODS: This is a prospective observational study of older patients with cancer who underwent oncosurgery in a tertiary cancer centre during the one-year study period. Patients were scored on the CFS, MFI, ASA and ECOG scales. All patients were followed up for 30 days immediately following surgery and their post operative complications were documented. Univariate and multivariate analyses were done and a p value of ≤0.05 was considered statistically significant. RESULTS: Of the 820 patients studied, 15.6% had prolonged hospital stay, 9.1% had 30-day morbidity, 0.7% had readmission, and mortality was 1.1%. High-risk scores on the ASA and CFS were significantly associated with prolonged postoperative stay, readmission, morbidity, and mortality (p < 0.05). High-risk scores on the ECOG was significantly associated with prolonged hospital stay (p = 0.027), 30-day morbidity (p = 0.003), and mortality (p = 0.001), but not with readmission. There was no significant association between MFI score and the postoperative variables studied (p > 0.05). On multivariate analysis, morbidity was significantly associated only with male gender (p = 0.015), higher cancer stage (p = 0.005), higher ASA score (p = 0.029), and prolonged hospital stay (p = 0.001). Mortality was significantly associated only with emergency surgery (p = 0.012) and prolonged hospital stay (p = 0.004), and prolonged hospital stay was significantly associated with advanced cancer stage (p = 0.001) and emergency surgery (p = 0.02). CONCLUSIONS: In older patients undergoing cancer surgery, ASA and CFS are predictors of prolonged postoperative stay, morbidity, mortality, and readmission. A high-risk ECOG score is predictive of prolonged post operative stay, 30-day morbidity, and mortality, but not of readmission. Score on MFI is not a predictor of postoperative outcomes. Newer predictive tools which include cancer- specific factors are required for better management of these patients.

Is Young Age an Independent Prognostic Factor in Carcinoma Breast? A Single-Institution Retrospective Comparative Study from South India.

Breast cancer is the most common cancer in women globally(1). It is usually a disease of old age. The incidence of breast cancer in females younger than 40 years is as low as 0.5%. Disease in patients with age less than or equal to 40 years at diagnosis is usually considered a young breast cancer(2). Occurrence of more adverse pathological features like triple negative and Her2 positive breast cancer as well as lacking reliable screening methods in young women leads to the poor prognosis in this group of patients(3). In the present study we aim to find the clinical and pathological characteristics of breast cancer in young women and their survival outcome for 5 years comparing the same with those characteristics of the older patients. Patients with nonmetastatic carcinoma breast who had registered at Regional Cancer Centre, Trivandrum, during the year 2012 were selected for the study. Patient's details including the clinicopathological features, treatment details, oncologic outcomes including recurrence, and survival data until 31 July 2019 were collected from treatment files kept in the hospital and via telephonic interview. Kaplan-Meier method was employed for survival analysis. Survival comparison was done using the log-rank test. Cox proportional hazards regression analysis was done for assessing the risk. Out of 1611 curatively treated patients with carcinoma breast, 281 (17.44%) were young breast cancer (equal to or less than 40 years). The median follow-up period was 82 months. Median age of diagnosis was 51.3 years. Young patients presented with larger tumour size, but nodal stage and composite stage, were not different. They had more TNBC status, 35% vs. 24%, p = 0.001. Young patient group had a drop in 5-year OS but statistically insignificant (75.9% vs. 82.5%, p = 0.179) and marginally significant drop in DFS (68.1% vs. 73.8%, p = 0.064). The proportion of young breast cancer is very high in the Indian population. Age is not an independent risk factor for worse prognosis. T and N stage, Her2nue status, and adequacy of nodal clearance are the most important independent risk factors deciding the 5-year OS.

Limberg Flap in Breast Oncoplasty for Carcinoma Breast Revisited-a Tertiary Cancer Centre Experience.

Limberg flap is currently not commonly used in breast oncoplasty. We present our experience with Limberg flap reconstruction in breast cancer patients who underwent breast conservation surgery. This study was conducted at a tertiary cancer centre in Kerala, India. We reviewed the records of patients with breast cancer who underwent Limberg flap reconstruction with breast conservation surgery from 1st January 2020 to 31st October 2021. Data collected included age, quadrant of tumour, side of tumour, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications following surgery and breast deformity following surgery. Seventeen patients underwent Limberg flap reconstruction during the study period. The median age of the patients was 51 years. The commonest stage was cT1N0M0. Twelve patients underwent primary surgery and 5 post neoadjuvant chemotherapy. No patient had postoperative flap complications or breast deformity. Limberg flap is simple, versatile and robust and should be a part of the armamentarium of breast surgeons.

Quality of Life Post Breast Cancer Surgery: Comparison of Breast Conservation Surgery versus Modified Radical Mastectomy in a Developing Country.

Introduction Breast cancer survivors are the largest group of female cancer survivors. Oncologic breast surgery can have a profound impact on a woman's body image and sense of self that can significantly affect their quality of life (QOL). The paucity of data about the effect of type of surgery on QOL of Indian breast cancer survivors has led to this study. Materials and Methods This prospective study included consecutive female early breast cancer patients who underwent primary surgery, that is, breast conservation surgery (BCS) or modified radical mastectomy (MRM) from January 1, 2015 to December 31, 2015. The primary objective was the comparison of QOL using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and EORTC QLQ-BR 23 between the two groups at 6 months and 1 year postsurgery with the baseline. Results One hundred and thirty-eight patients were included of which 62 underwent BCS and 76 underwent MRM. BCS patients fared better with respect to physical functioning, dyspnea, fatigue, appetite loss, and body image at 6 months ( p < 0.05) as compared with MRM. At 1 year postsurgery, BCS patients fared better with respect to physical functioning, role functioning, global health status, body image, sexual enjoyment, and dyspnea, while MRM patients fared better in emotional functioning and future prospectives ( p < 0.05). Conclusion Patients undergoing BCS have a better QOL with respect to various functional and symptom scales at 6 months and 1 year. However, patients undergoing MRM perform better in terms of future perspective and emotional functioning at 1 year.

Acceptability, Utility, and Cost of a Mobile Health Cancer Screening Education Application for Training Primary Care Physicians in India.

PURPOSE: Mobile health (mHealth)-based oncology education can be a powerful tool for providing cancer screening knowledge to physicians, as mobile technology is widely available and inexpensive. We developed a mobile application (M-OncoED) to educate physicians on cancer screening and tested the acceptability, utility, and cost of two different approaches to recruit physicians. METHODS: M-OncoED was designed to perform pre- and postlearning assessments through the in-built quizzes; present case studies and educational materials for cervical, breast, and oral cancer screening; collect responses to interactive queries; document module completion; send reminders and alerts; and track user metrics, including number of sessions to complete each module and time spent per session. We tested two recruitment approaches: a broad-scale recruitment group, for which we relied on e-mails, messaging apps (e.g., WhatsApp), and phone calls, and the targeted recruitment group, for which we conducted a face-to-face meeting for the initial invitation. RESULTS: Overall, about 35% of those invited in the targeted group completed the course compared with about 3% in the broad-based recruitment group. The targeted recruitment approach was more cost-efficient ($55.33 vs. $109.43 per person). Cervical cancer screening knowledge increased by about 30 percentage points, and breast cancer screening knowledge increased by 10 percentage points. There was no change in knowledge for oral cancer scorings. CONCLUSION: This study has demonstrated the feasibility and utility of using an mHealth app to educate physicians. A more intensive hands-on recruitment approach is likely required to engage physicians to download and complete the app. Future studies should assess the impact of mHealth tools on physician behavior and patient outcomes. IMPLICATIONS FOR PRACTICE: Mobile health (mHealth)-based oncology education can be a powerful tool for providing cancer screening knowledge to physicians, as mobile technology is widely available and inexpensive. This study has demonstrated the feasibility and utility of using an mHealth app to educate physicians and illustrates the type of recruitment approach (face-to-face) that is likely required to incentivize physicians to download the app and complete the training.

Nipple Areola Complex Involvement in Invasive Carcinoma Breast.

A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.

Superficial incisional surgical site infections in emergency surgery in cancer patients: A tertiary cancer care center experience.

OBJECTIVE: The objective of this study is to review the superficial incisional surgical site infections (SISSIs) in emergency surgery in cancer patients. MATERIAL AND METHODS: The microbiological culture and sensitivity reports of patients undergoing emergency surgery for cancer of 1 year (April 2016 to March 2017) were analyzed along with the clinical factors associated with it from a surgeon's perspective. RESULTS: Of the 308 patients who underwent surgery, SISSI rate was 11.7%. The most common organism was Escherichia coli (27%) followed by enterococci (21%). Prolongation of hospital stay was average 2 days. Mortality rate among SISSI patients was 7.9%. Concordance among ongoing antibiotic and culture was 72%. CONCLUSION: Regular review of the current microbial spectrum and its antibiotic spectrum is required, especially in immunocompromized cancer patients.

Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre.

The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.