Practice Patterns and Survival in Patients with Resected Pancreatic Ductal Adenocarcinomas (PDAC) - Results from the Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) Study.

BACKGROUND: There is limited data from India with regard to presentation, practice patterns and survivals in resected pancreatic ductal adenocarcinomas (PDACs). METHODS: The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) included data from 8 major academic institutions across India and presents the outcomes in upfront resected PDACs from January 2015 to June 2019. RESULTS: Of 288 patients, R0 resection was achieved in 81% and adjuvant therapy was administered in 75% of patients. With a median follow-up of 42 months (95% CI: 39-45), median DFS for the entire cohort was 39 months (95% CI: 25.4-52.5), and median overall survival (OS) was 45 months (95% CI: 32.3-57.7). A separate analysis was done in which patients were divided into 3 groups: (a) those with stage I and absent PNI (SI&PNI-), (b) those with either stage II/III OR presence of PNI (SII/III/PNI+), and (c) those with stage II/III AND presence of PNI (SII/III&PNI+). The DFS was significantly lesser in patients with SII/III&PNI+ (median 25, 95% CI: 14.1-35.9 months), compared to SII/III/PNI + (median 40, 95% CI: 24-55 months) and SI&PNI- (median, not reached) (p = 0.036)). CONCLUSIONS: The MIPPAP study shows that resectable PDACs in India have survivals at par with previously published data. Adjuvant therapy was administered in 75% patients. Adjuvant radiotherapy does not seem to add to survival after R0 resection.

Interaortocaval Lymph Node Metastasis in Gall Bladder Cancer: Is It Regional Node or Metastatic Disease?

BACKGROUND AND OBJECTIVES: Interaortocaval or para-aortic lymph node (IACLN) metastasis in gall bladder cancer (GBC) is usually a contraindication to curative resection with a prognosis similar to liver or peritoneal metastases. However, few authors have reported survival similar to regional lymph node (RLN) positive disease after curative resection in these patients. This study aims to analyse the role of curative surgery in such cases. METHODS: Data of all patients operated for GBC from 2012 to 2019 was retrieved. Survival of the IACLN- and RLN-positive patients was compared and factors associated with recurrence and survival were analysed. RESULTS: Patients were divided in RLN-positive (n = 47) and IACLN-positive (n = 17) group. At a median follow-up of 19.7 months, median disease-free survival (18 vs 13 months) and median overall survival (27 vs 20 months) were inferior (p = 0.06) in IACLN group. But it was higher than the patients who received only palliative therapy (median OS, 14 months). Lack of adjuvant therapy was a significant factor for disease recurrence. CONCLUSION: Selected cases of GBC with IACLN metastases can achieve meaningful survival after curative resection and adjuvant therapy. Survival was inferior to RLN-positive cases but it was higher than the patients who received only palliative chemotherapy. This concept needs further evaluation in a prospective study with larger number of patients.

Robot assisted minimally invasive esophagectomy: safety, perioperative morbidity and short-term oncological outcome-a single institution experience.

Robot assisted minimally invasive esophagectomy (RAMIE) has evolved over the past decade to become procedure of choice at many centers all over the world. The objective of this study is to present our experience of robot assisted minimally invasive esophagectomy with respect to perioperative morbidity and short-term oncological outcomes and a comparison of the same to a cohort of our patients who underwent open Mckeown's esophagectomy. This is a retrospective analysis of prospectively collected data of patients from October 2011 to October 2019. A total of 56 patients in open group and 58 patients in robotic group were enrolled. Upper and middle third was the most common site for open esophagectomy while middle and lower third was more common site for robotic esophagectomy (p < 0.0001). Median operative time was 340 min for open and 360 min for robotic esophagectomy (p = 0.004). A median of 16 lymph nodes were retrieved in either group. R0 resection was achieved in 86% in open and 97% in robotic group (p = 0.04). Median intensive care unit (ICU) stay (2 days versus 5 days) and median hospital stay (10.5 days versus 14.5 days) were both favoring for robotic group (p < 0.0001). Cardiac arrhythmias and pulmonary complications requiring ICU readmission occurred less frequently in patients undergoing robotic esophagectomy (p = 0.02). Two-year overall survival (p = 0.09) and 2-year disease-free survival (p = 0.32) was similar between the groups. RAMIE significantly reduced ICU as well as hospital stay and had oncological outcome similar to open Mckeown's esophagectomy.

Combination of portal vein embolization and neoadjuvant chemotherapy for locally advanced gallbladder cancer requiring extended hepatectomy - A novel approach.

BACKGROUND: Locally advanced gallbladder cancer (GBC) may require extended hepatectomy. Portal vein embolization (PVE) can lead to hypertrophy of future liver remnant (FLR), and neoadjuvant chemotherapy (NACT) can be used in this cohort, with additional advantage of downstaging tumors as well as preventing progression while waiting for liver regeneration. Here, we share our experience of combining NACT along with PVE in locally advanced GBC requiring major hepatectomy. METHODS: Retrospective analysis of prospectively maintained database was conducted for patients with locally advanced GBC who underwent PVE and received NACT between 2012 and 2018. RESULTS: Fourteen patients with locally advanced GBC underwent PVE and NACT. Median baseline FLR volume was 25.09% with a median degree of hypertrophy of 8.8% after PVE. Out of 14 patients, 7 (50%) underwent curative resection. Median overall survival in resectable and unresectable patients was 27 months and 15 months respectively. CONCLUSION: PVE along with NACT made curative surgery feasible in half of the patients who were deemed unresectable initially.

Multimodality management of gallbladder cancer can lead to a better outcome: Experience from a tertiary care oncology centre in North India.

BACKGROUND: Surgical resection is a treatment of choice for gallbladder cancer (GBC) patients but only 10% of patients have a resectable disease at presentation. Even after surgical resection, overall survival (OS) has been poor due to high rates of recurrence. Combination of surgery and systemic therapy can improve outcomes in this aggressive disease. AIM: To summarize our single-center experience with multimodality management of resectable GBC patients. METHODS: Data of all patients undergoing surgery for suspected GBC from January 2012 to December 2018 was retrieved from a prospectively maintained electronic database. Information extracted included demographics, operative and perioperative details, histopathology, neoadjuvant/adjuvant therapy, follow-up, and recurrence. To know the factors associated with recurrence and OS, univariate and multivariate analysis was done using log rank test and cox proportional hazard analysis for categorical and continuous variables, respectively. Multivariate analysis was done using multiple regression analysis. RESULTS: Of 274 patients with GBC taken up for surgical resection, 172 (62.7%) were female and the median age was 56 years. On exploration, 102 patients were found to have a metastatic or unresectable disease (distant metastasis in 66 and locally unresectable in 34). Of 172 patients who finally underwent surgery, 93 (54%) underwent wedge resection followed by anatomical segment IVb/V resection in 66 (38.4%) and modified extended right hepatectomy in 12 (7%) patients. The postoperative mortality at 90 d was 4.6%. During a median follow-up period of 20 mo, 71 (41.2%) patients developed recurrence. Estimated 1-, 3-, and 5-years OS rates were 86.5%, 56%, and 43.5%, respectively. Estimated 1- and 3-year disease free survival (DFS) rates were 75% and 49.2%, respectively. On multivariate analysis, inferior OS was seen with pT3/T4 tumor (P = 0.0001), perineural invasion (P = 0.0096), and R+ resection (P = 0.0125). However, only pT3/T4 tumors were associated with a poor DFS (P < 0.0001). CONCLUSION: Multimodality treatment significantly improves the 5-year survival rate of patients with GBC up to 43%. R+ resection, higher T stage, and perineural invasion adversely affect the outcome and should be considered for systemic therapy in addition to surgery to optimize the outcomes. Multimodality treatment of GBC has potential to improve the survival of GBC patients.

Use of 18F Fluorodeoxyglucose Positron Emission Tomography Computed Tomography in Assessing Response to Neoadjuvant Chemoradiation and Its Impact on Survival in Esophageal Squamous Cell Carcinoma.

BACKGROUND: To determine the accuracy of 18F-Fluorodeoxyglucose positron emission tomography computed tomography (FDG-PET CT) in predicting response to neoadjuvant chemoradiation (NACRT) in esophageal squamous cell cancer (SCC) and impact of such response on survival. METHODS: Retrospective analysis of patients with esophageal SCC (cT2-4N0-N+M0) who underwent PET CT before and 6 weeks after NACRT followed by surgery was carried out in this study. Metabolic response was assessed by change in standardized uptake value (ΔSUVmax) after NACRT and the pathological response was graded. A receiver operating characteristic curve (ROC) was used to identify the optimal cut off value of SUVmax to predict histopathological response. The impact of metabolic response and pathological response on survival was determined. RESULTS: Of the 73 patients analyzed, 27 had complete metabolic response, while 24 had pathological complete response (PCR). However, only 14 of the 27 complete metabolic responders actually had PCR. At 67% ΔSUVmax, the optimum balance between sensitivity (70.83%) and specificity (69.23%) was achieved and the correlation between metabolic response and pathological complete response achieved statistical significance (p = 0.0009). However, ΔSUVmax of 67% was found to have no significant association with survival (p = 0.51). PCR was the only significant determinant of improved survival (p = 0.04). CONCLUSION: PCR which is a significant determinant of survival is not ideally predicted by ΔSUVmax on PET CT.

18-FDG PET-CT should be included in preoperative staging of gall bladder cancer.

BACKGROUND: Only few retrospective studies have looked into the ability of PET-CT to diagnose distant metastases in gall bladder cancer (GBC) patients with variable results. This study aims to determine the utility of PET -CT in potentially resectable GBC. METHODS: All GBC patients with resectable disease on CECT chest, abdomen & pelvis were subjected to FDG- PET-CT scan. Incidental GBC was excluded. All additional findings and change in management plan was recorded. RESULTS: Out of 149 patients, 99 (66.4%) were females and the mean age was 56.7 ± 11.0 years,. After PET scan, additional findings were seen in 46/149 (30.9%) patients and it lead to change in management plan in 35 (23.4%) patients due to the presence of distant metastases. Impact of PET scan in changing the stage was higher in patients having node positive disease on CECT (26/96, 27%) as compared to node negative patients (9/53, 16.9%), but this difference was not statistically significant (p = 0.233). After assessment on CECT, 76 patients were planned for NACT in view of locally advanced disease but after PET-CT in these patients, the management plan changed to palliative chemotherapy in 26 (34.2%) cases whereas it changed in only 9 out of 73 (12.3%) patients who were planned for upfront surgery (p = 0.003). CONCLUSION: Our results show that preoperative staging workup for GBC should include PET-CT as it changed the management plan in approximately one-fourth of all resectable GBC patients and in one-third of locally advanced cases.

Large Retroperitoneal Extraosseous Osteosarcoma Invading into the Spine: a Case Report.

Extraosseous osteogenic sarcoma is a very rare malignant neoplasm. The most common sites are the extremities, thorax, and the abdomen. Retroperitoneal osteosarcomas are rare and very few cases have been reported. They are similar in their biology to high-grade soft tissue sarcomas. R0 resection appears to be the best possible treatment for these tumors but there are no published cases on how to manage them when it involves posterior and intra-spinal regions. We report a 62-year-old male who presented with a backache, and investigations revealed a large retroperitoneal fibrosarcoma invading into the lumbar spine, but was found to be an extra osseous osteosarcoma on final histopathological examination. It is important to emphasize that due to the rarity of soft tissue sarcomas as well as the uniqueness of the multimodal treatment plan for each subtype, soft tissue sarcomas involving the spine are best managed by a multi disciplinary team. Overall, patients with soft tissue sarcomas involving the spine usually present a poor long-term prognosis. Therefore, whenever feasible, "en bloc" resection of such lesions has been shown to play a crucial role in improving the overall and recurrence-free survival rates.