Evaluation of Various Surgical Options in Post-irradiation Cancer Cervix with Central Residue or Recurrence.

The standard treatment for post-irradiation cancer cervix with central residue or recurrence is pelvic exenteration. Some of the carefully selected patients with lesions of size less than 2 cm may be treated with radical hysterectomy. Patients treated by radical hysterectomy have less morbidity rates when compared to pelvic exenteration. The parameters for defining a subset of these patients have not been addressed. Given the changing scenario of organ preservation, we have to determine the role of radical hysterectomy after radical or defaulted radiotherapy treatment. Retrospective analysis of patients with post-irradiation cancer cervix with central residue or recurrence who were treated by surgery from 2012 to 2018 was done. The initial stage of the disease, radiation treatment details, recurrence/residue, extent of disease as per imaging, surgical findings, histopathological examination report, post-surgery local recurrence, distant recurrence and 2-year survival rates were analysed. A total of 45 patients were found eligible for the study from the database. Nine (20%) patients, who had tumours that were confined to cervix, size less than 2 cm with preserved planes of resection, underwent radical hysterectomy and the other 36 (80%) patients underwent pelvic exenteration. Among patients who underwent radical hysterectomy, one (11.1%) patient had parametrial involvement and all of them had tumour-free resection margins. Among patients who underwent pelvic exenteration, 11 (30.6%) patients had parametrial involvement and five (13.9%) patients had tumour infiltrated resection margins. Among patients who were treated by radical hysterectomy, the local recurrence rate was high in patients who had a pretreatment FIGO stage of IIIB when compared to stage IIB (33.3% vs. 20%). Out of the nine patients treated by radical hysterectomy, two patients had local recurrence and both of them did not receive brachytherapy preoperatively. In patients with an early stage carcinoma cervix with post-irradiation residue or recurrence, radical hysterectomy can be considered if the patient consents to participate in a trial, willing to be on strict follow-up and understands the postoperative complications. Large-scale studies for radical hysterectomy have to be done on post radical irradiation small volume early stage residue or recurrence, to identify the parameters for safe and comparable oncological outcomes.

Managing cancer during COVID pandemic - Experience of a tertiary cancer care center.

OBJECTIVE: The COVID-19 pandemic has forced healthcare providers worldwide to bring in changes in the way cancer patients are cared for. Many cancer departments globally have brought in changes to their daily practice. This article is about our experience of evolving "COVID 19 PROTOCOL" devised in our department and taking a shape to suit a health care system with limited budget. MATERIALS AND METHODS: All the patient census & details of department of surgical oncology, Royapettah cancer hospital, from month of March 2020 to July 2020, who were subjected to COVID protocol were compared to patient census of similar duration in immediate past five months of October 2019 to February 2020. The data from out-patient department, ward in-patient census and healthcare personnel data was analyzed. RESULTS: There was a drop to 63.5% in OP census and 61.6% in IP census. There was a drop to 64.5% in number of major cases operated during initial phases of COVID pandemic. Health care workers were also infected with the COVID but cross infectivity can be checked if proper steps to adhere to an institutional protocol based on general measures of cleanliness are taken. CONCLUSION: Adherence to an institutional protocol based on compliance to general measures of masking, hand washing and social distancing plays a major role in minimizing disease spread. The Royapettah COVID protocol, though in process of evolution, can be recommended for any health care center with limited resources.

Surgical Management of Bone Sarcomas with an Inappropriate Biopsy Site: A Case Series and Review of Literature.

AIM: To study bone sarcoma patients who underwent limb salvage surgery with an inappropriate biopsy site and their surgical management. MATERIALS AND METHODS: There were 28 patients with bone sarcoma who underwent limb salvage surgery from 2015 - 2019, among them 4 patients had inappropriate biopsy scar. They were analyzed with respect to modification of incision, extent of flap elevation, difficulties in exposure of neurovascular structures, reconstructive methods and post-operative wound morbidity. RESULTS: In all cases biopsy was done in outside hospital. One patient had open biopsy, remaining all were core needle biopsies. Out of the 4, three patients had distal femur lesion and one patient had proximal tibial lesion. Patient with proximal tibial lesion had biopsy site placed anteriorly over tibia. Patient underwent proximal tibial resection with anteromedial incision. Remaining three patients had distal femur lesion. One patient had pathological fracture with internal fixation done with lateral incision, and biopsy site placed medially. During surgery lateral incision was taken to include internal fixation scar with the distal end curved medially and extended over leg after including the biopsy site. One patient had distal femur lesion with laterally placed biopsy site, surgery done with lateral approach and medial gastrocnemius flap used to cover the prosthesis. One patient had anteriorly placed biopsy site, so after including the inappropriate biopsy site the lateral incision was curved medially and extended over leg. Two out of these four patients had skin necrosis; one patient had partial thickness skin necrosis and the other full thickness skin necrosis which was managed conservatively. CONCLUSION: In case of limb salvage surgery, skin incisions should be planned taking extent of lesion and biopsy scars into account. Good knowledge of vascular supply and incisions required if and when surgery is planned helps in selecting proper site for biopsy.

Anaplastic Carcinoma Thyroid - A Review on the Management of this Aggressive Cancer.

Anaplastic carcinoma thyroid is an aggressive malignancy with very poor survival rate. In this study, we reviewed the records of 34 patients with anaplastic carcinoma thyroid in our centre and we divided them into groups T4a, T4b, and T4c. The case records were reviewed for presentation, diagnosis, treatment and follow-up and we analysed the data using statistical methods. The median age group was 65 years with 22 women and 12 men. There were 16 patients (47%) with a history of thyroid swelling of more than 2 years duration. Of these 16 patients 6 were found to be in T4a group. There were 6 patients in T4a, 14 each in T4b and T4c. All the patients in T4a group were operated and completed multimodal management. The group with T4a had the best prognosis with a mean survival of 1 year. The patients with extracapsular disease (T4b) completed chemotherapy along with radiotherapy. These patients had a mean survival of 6 months. Only 2 patients in metastatic group completed the course of chemotherapy with radiotherapy. The other 12 patients died during the course of treatment due to respiratory failure. The mean survival in this group was a dismal 15 days. On univariate analysis metastatic disease, extracapsular disease, size more than 5 cm and involvement of lymph nodes were the reasons for incomplete treatment and hence markers of worst prognosis. There are 47% of the patients with prior history of thyroid swelling which gives us time to identify and manage thyroid swellings with propensity to undergo anaplastic transformation.

Axillary dissection for breast cancer using electrocautery versus ultrasonic dissectors: A prospective randomized study.

BACKGROUND: The major morbidities of modified radical mastectomy both short- and long-term are sequelae of axillary dissection. Flap complications, prolonged seroma, need for axillary drainage, wound infection, lymphedema, shoulder stiffness, and paresthesia are major causes for morbidity after axillary dissection. Different techniques have been implemented to tackle these problems. Few of these include reducing the axillary dead space, using various forms of energy devices. AIMS: We have prospectively compared two energy sources, namely, ultrasonic dissector (UD) against the electrocautery dissection in axillary dissection for breast cancer with respect to outcomes. MATERIALS AND METHODS: One hundred female patients with breast cancer undergoing modified radical mastectomy were randomized to either of the two arms - axillary dissection using UD and axillary dissection using electrocautery. The parameters taken into consideration were operating time, operative blood loss, amount and duration of axillary drainage, flap complications, nodal yield, and postoperative pain scoring. RESULTS: There were no significant differences overall between the two groups with respect to oncological safety and functional outcomes.

Temporalis Muscle Flap in Head and Neck Reconstructions Is That Forgotten or Forbidden? Our Case Series and Review of Literature.

Temporalis muscle flap is a versatile flap which can be used for reconstruction after major head and neck resections, owing to its optimal bulk, constant and reliable vascularity, ease of access to recipient site, minimal donor site morbidity and relatively better cosmetic outcome compared to more bulky flaps like pectoralis major myocutaneous flap or deltopectoral flap. The flap can be used as a muscle flap, myofascial flap (muscle with temporalis fascia). We present our series of 12 cases of temporalis muscle flap reconstruction for various head and neck reconstructions. The aim of this study was to analyse the application of temporalis muscle flap in head and neck reconstructions and its outcome.

Approach to carcinoma cervix with pelvic kidney.

To study the management of carcinoma cervix when the patient has an associated pelvic kidney. The simultaneous occurrence of carcinoma cervix and pelvic kidney is rare. It is an interesting scenario where surgery is technically challenging and radiation is difficult since the pelvic kidney lies within the field of radiation. In our department, we treated three cases of cervical carcinoma with pelvic kidney. First case was FIGO IIB treated with external beam radiotherapy followed by radical hysterectomy; second case stage IB1 treated with radical hysterectomy, third case was referred to us after panhysterectomy with carcinoma detected in postoperative histopathological report, and she was treated with external beam radiotherapy. We made an online database search and found few case reports of gynecological malignancies associated with pelvic kidney and reviewed their management. All the three patients are alive and disease free in the last follow up. None of the patients developed uremia. The pelvic kidney of the patients treated with radiotherapy has shrunken in size. Surgery is preferred over radiotherapy in early stages of carcinoma cervix with pelvic kidney to avoid radiation-induced damage to pelvic kidney.