Predictive Factors for Submandibular Gland Involvement in Oral Cavity Squamous Cell Carcinoma-a Prospective Study from a Tertiary Cancer Center.

The oncological necessity of submandibular gland removal during neck dissection for oral cavity squamous cell carcinoma surgery has remained controversial. This study was aimed to determine the rate of SMG involvement and assess the feasibility of submandibular gland (SMG) preservation. We present a prospective study conducted at a tertiary cancer center from June 2017 to May 2019. All patients of oral squamous cell carcinoma who underwent primary surgery with neck dissection were included and analyzed for incidence and predictive factors for incidence of level IB nodal and SMG involvement as per CAP guidelines. A total of 60 patients were inducted in the study, wherein 63 neck dissections were performed including bilateral dissection in three cases. There was involvement of SMG in 6 patients with two cases each in floor of mouth cancer, gingivo-buccal, and alveolar lesions. The SMG was involved by direct contiguous spread from the primary lesion in two cases, extra-capsular extension from level IB lymph nodes in one and by both mode of spread in three glands. Perineural invasion was seen in 83.33% (n = 5) patients with SMG involvement (p- < 0.001), while 66.67% (4/6) patients had lympho vascular invasion (p-0.006) and all the cases with SMG involvement had extra-capsular extension (p < 0.001), suggesting PNI, LVI, and ECE as the strongest predictors of SMG involvement. This study demonstrates that oral cavity squamous cell carcinoma has low potential to metastasize to the SMG; however, high-risk factors include primary tumor site in floor of mouth or tongue, heavy level IB nodal burden, presence of LVI, PNI, and ECE. In the absence of these high-risk factors, SMG preservation with complete nodal clearance in level IB is a promising technique for reducing future complications.

High-Grade Endometrial Cancer-Behaviour and Outcomes at a Tertiary Cancer Centre.

High-grade endometrial carcinomas are a heterogeneous group of clinically aggressive tumours. They include FIGO grade 3 endometrioid adenocarcinoma, uterine papillary serous carcinoma (UPSC), clear cell carcinoma, undifferentiated carcinoma and carcinosarcomas or malignant mixed Mullerian tumour (MMMT). The aim of this study is to look at clinicopathological features and survival outcomes of high-grade endometrial cancers of the uterus in our centre. A tertiary care centre in India. The study design is retrospective with survival analysis. We did a retrospective analysis of all patients admitted with a diagnosis of high-grade uterine carcinoma. Data regarding baseline characteristics, disease profiles, surgical outcomes, complications, extent of surgical staging, duration of surgery, blood loss, length of hospital stay, drain output, wound infection, surgico-pathological stage and grade, tumour size and location, myometrium and lymphovascular invasion, node positivity, adjuvant treatment, overall survival and recurrence-free survival. Survival analysis was done using the Kaplan-Meier method. We had 115 females diagnosed with endometrial cancer. Of these, 40 patients had high-grade endometrial cancer. Mean age at presentation was 64.7 years (range 33-80 years). Of this, endometrioid adenocarcinoma grade III was the commonest (37.5%), followed by UPSC in 32.5% and MMMT in 22.5% patients. Clear cell variant and mixed dedifferentiated variant were reported in 5% and 2.5%, respectively. Over 48 months of follow-up, recurrence was detected in eight patients (20%) and median time to recurrence was 11 months. Mean recurrence-free survival was 32.8 months and mean overall survival was 38.6 months High-grade endometrial cancers are aggressive tumours of postmenopausal women. Surgical staging and combination chemotherapy along with radiation therapy are the mainstay of treatment. In spite of adequate debulking followed by adjuvant therapy, survival remains poor.

Can Preoperative Ultrasonography and MRI Replace Sentinel Lymph Node Biopsy in Management of Axilla in Early Breast Cancer-a Prospective Study from a Tertiary Cancer Center.

Although SLNB is a less invasive procedure in detecting axillary lymph node metastases(ALNM) in early breast cancer; still, it carries some complications like lymphedema and in addition, performing SLNB requires surgical skills, technical knowledge, presence of facility like preoperative sentinel lymphoscintigraphy, and availability of hand-held gamma probe for intraoperative assessment. We calculated the relative diagnostic strength of preoperative axillary USG and MRI and compared with of SLNB for detection of ALNM in early breast cancer and assessed whether MRI and USG could accurately predict axillary LN status, potentially replacing SLNB. We evaluated 40 cases of clinically node-negative early breast cancer with preoperative axillary USG and MRI and subsequently subjected to SLNB. The sensitivity, specificity, PPV, NPV, and accuracy of axillary USG were 62.5%, 96.88%, 88.33%, 91.18%, and 90% respectively (p value < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of MRI in detection of ALNM were 75%, 93.75%, 75%, 93.75%, and 90% (p value < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of combined USG and MRI in detection of ALNM were 87.5%,90.63%, 70%, 96.67%, and 90% respectively (p value < 0.001), which are comparable to previous study series. The diagnostic performance of combined approach of axillary USG and MRI is promising, as the NPV of combined USG and MRI is approaching the NPV of the SLNB in detecting ALNM. Based on above findings, if axillary LNs are found nonsuspicious in preoperative axillary USG and MRI, further axillary dissection may be avoided, and if found suspicious, then ALND may be directly proceeded avoiding SLNB in between.

Oncoplastic Breast Reconstruction in Breast Conservation Surgery: Improving the Oncological and Aesthetic Outcomes.

Breast conservation surgery (BCS) is now the standard of care for patients with early breast cancer. The main contraindications for BCS besides the presence of multicentricity and diffuse microcalcifications are inadequate tumour size to breast size ratio. With the advent of oncoplastic techniques, the indications of BCS may be further extended to patient with larger tumour size and or small volume breast. We prospectively assessed 42 patients undergoing oncoplastic breast conservation surgery for cosmetic and oncologic outcomes. Cosmetic outcome assessment was done by comparison of operated breast to contralateral breast by an independent surgeon, nurse and patient's attendant at 6 months post-surgery. Risk factors for compromised oncologic outcomes included grades II/III tumours and non-ductal histology. Intraoperative margin assessment with frozen section analysis proved to be important in order to achieve negative surgical margins on final histopathology. By univariate analysis, tumours located in central quadrant and medial half of the breast had similar cosmetic outcomes comparable to tumours located in other quadrants. Majority of our patients (90%) had overall good to excellent cosmetic outcomes on Harvard scale. Oncoplastic breast conservation surgery techniques allow for larger parenchymal resections without compromising oncologic and cosmetic results. It further allows extension of BCS to patients otherwise denied for the same based on earlier recommendations for mastectomy. Oncoplastic techniques and intraoperative margin assessment with frozen section are vital in attaining adequate margins and also decrease chance of local recurrence and revision surgery for positive margins.

Surgical Management of Carcinoma Vulva-Case Series and Review of Literature.

The objective of this study was to study the risk factors, management protocols, and the outcome of vulvar cancer cases over a period of 2 years in a tertiary care hospital. This is a case series of early-stage vulvar cancer in the Department of Surgical Oncology in BL Kapur Superspeciality Hospital from Jan 2016 to date. Five patients with histologically proven diagnosis of early-stage vulvar cancer were included. The mean age for the diagnosis of vulvar cancer was 58 years and the peak incidence was seen in postmenopausal age group. All of the cases were squamous cell carcinomas in stage IB except one which was a basisquamous variant. All cases were treated primarily with surgery and vulvar flap reconstruction. Adjuvant therapy was not given in any case. Cases were followed from 6 months to date, and no recurrence noted. The limitations of the study were rarity of disease and less number of cases. As all the cases in our study were in early stage of disease (stages I and II), surgical treatment in the form of modified radical vulvectomy with B/L inguinofemoral lymph node dissection and oncoplastic procedure was the treatment modality chosen for all the patients.

Immunoglobulin G4 related pancreaticobiliary disease: Report of two cases highlighting the diagnostic criteria.

Two cases of immunoglobulin (IgG4)-related biliary and pancreaticobiliary disease are reported to define its diagnostic features. Case 1 presented with obstructive jaundice and showed IgG4-related disease (RD) involving right and left hepatic duct, common bile duct and gallbladder. Case 2 presented as periampullary mass. Both patients underwent surgical intervention. However, certain clinical and radiological features were present in these cases indicative of the possibility of IgG4-RD.

Multiple Gastrointestinal Cancers in a Single Patient-a Rare Clinical Entity.

Multiple gastrointestinal cancers in a single patient is a rare entity. In our study, we are showing the clinical presentation and management of these patients. A fifty-nine-year-old asthenic male (already treated case of metachronous colorectal cancer in 2008 and 2011) presented with complaints of generalized weakness and fatigue. Strong family history was present with two of his first-degree relatives having diagnosed with gastrointestinal cancer at the age < 50 years with one of them having stomach carcinoma and another with GEJ tumors. On evaluation, upper GI endoscopy revealed growth at cardia and endoscopic biopsy revealed adenocarcinoma. Radiological evaluation with PET-CT scan revealed proximal stomach growth with regional lymphadenopathy. Patient was optimized for surgery and underwent D2 total gastrectomy, distal pancreatectomy and splenectomy with Roux-en-Y oesophago-jejunal anastomosis. Pathological stage revealed pT4N2M0, moderately differentiated adenocarcinoma of proximal stomach, both distal and proximal cut margins negative for tumor, LVI present with no perineural invasion, and 5/18 lymph nodes dissected were positive for malignancy. Genetic testing needs to be considered in this patient (modified Bethesda guidelines and IGCLC criteria). Familial gastric cancer are of two types: (a) hereditary diffuse gastric cancer syndrome, (b) familial intestinal type gastric cancer. Approximately 5% of patients have germ-line mutations-AD LYNCH syndrome, hereditary breast-ovarian cancer, and polyposis and non-polyposis syndrome. Once diagnosed in localized advanced stage, the best treatment is R0 resection though overall prognosis in these patients is very poor. So it is rationale to find such families with elevated risk and to do active surveillance for early diagnosis and providing prophylactic gastrectomies to them as it has proven to be beneficial in hereditary form of gastric cancer.

Reconstruction in Breast Conservation Therapy-Single Tertiary Care Institution Experience with 472 Patients.

Breast conservation therapy (BCT) is now internationally accepted treatment for early breast cancer. Despite of high incidence of carcinoma breast in India, BCT rates are very low as compared to the west. In this article, we wish to share our experience of breast conservation with oncoplasty in Indian women. A retrospective analysis of case records of patients treated with oncoplastic breast conservation from January 2009 to June 2014 in a single surgical oncology unit in a tertiary cancer institute. Demographic patient data, stage of disease, location of primary tumour, use of neo-adjuvant chemotherapy if received, tumour size and breast size ratio, reconstruction method used, post-operative complications and aesthetic score of patients were analysed. Various methods of oncoplasty and partial breast reconstruction used are discussed. Four hundred and seventy-two patient records were found suitable for analysis. Most common stage of presentation was T2N0 in 189 patients (40%). Forty-one patients received neo-adjuvant chemotherapy (NACT). Tumour arising in upper outer quadrant was most common site, seen in 268 (56.7%). The most common method of reconstruction was volume displacement, done in 57.6% patients. Overall surgical complications included wound infection with or without dehiscence, seroma formation, partial flap necrosis and fat necrosis. Cosmesis was found to be excellent in 23.09% and good in 58.47% at 6-month follow-up. Breast conservation with oncoplasty is oncologically safe for early breast cancer treatment and has good cosmetic outcome with high patient satisfaction rates. Its practice should be encouraged in Indian set-up also.

Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) for Prevention of Breast Cancer-Related Lymphedema-a Preliminary Report.

Lymphatic microsurgical preventing healing approach (LYMPHA) for prevention of breast cancer-related lymphedema (BCRL)-a preliminary report BCRL-is a chronic debilitating condition which impairs quality of life of breast cancer survivors. The aim is to study the feasibility of preventing lymphedema by performing "Lymphatic Microsurgical Preventive Healing Approach (LYMPHA)." Patients undergoing breast cancer surgery with complete nodal dissection were taken up for the study. After the standard axillary nodal dissection, lymphatics were identified by the help of blue dye and were anastomosed with a tributary to the axillary vein. Post-operatively, patients were followed up clinically for development of lymphedema and lymphoscintigraphy was performed after treatment completion. A total of 35 patients were enrolled for the study. The average BMI was 29.5. LYMPHA was feasible in all cases. The number of lymphatics identified was 1 to 5 per axilla. Two patients developed transient lymphedema which resolved with conservative therapy and patients were able to discontinue the compression garment. Follow-up lymphoscintigraphy is performed in two patients, which showed normal lymphatic flow. LYMPHA is a feasible technique, not difficult to perform, takes a short time, is accomplished in same general anesthesia as for axillary dissection, and gives no extra scar. The early results are promising and long-term follow-up may make the procedure as a routine.

The Futility of Systematic Lymphadenectomy in Early-Stage Low-grade Endometrial Cancer.

Lymphadenectomy is considered an integral part of comprehensive surgical staging of endometrial cancer but debate on the value of lymphadenectomy continues in early-stage endometrial cancer. The aim of our study was to determine the number of node positive patients in clinically early-stage low-grade (G1-G2) endometrioid endometrial cancer. We retro-prospectively analyzed the medical records of 155 women with endometrial pathology coming to the BLK cancer center between January 2015 and December 2017 and studied 60 patients of FIGO grade 1-2 endometrioid endometrial cancer confined to the uterus to determine the nodal positivity. Out of total 60 cases, 2 (3.3%) patients had positive nodes indicating the very low incidence of nodal positivity in clinically uterus confined low-grade endometrioid tumors. Both pelvic and para-aortic lymph nodes were positive in 1 patient. Skip metastases with para-aortic nodal positivity only while pelvic lymph nodes being negative were found in 1 (1.6%) patient. The necessity of comprehensive lymphadenectomy in endometrial cancer remains controversial. Sentinel node mapping can be a reasonably good alternative to strike a balance between systematic lymphadenectomy and no dissection at all in low and intermediate risk endometrial cancer.

Setting up of the Indian HIPEC Registry: A Registry for Indian Patients with Peritoneal Surface Malignancies.

There are various registries for patients with peritoneal metastases (PM) that aid pooling of data and generate evidence that dictates current clinical practice. This manuscript describes the setting up of the Indian HIPEC registry that was set up with a similar goal by a group of Indian surgeons. This is a registry for patients with PM treated with CRS and HIPEC in India. It also acts as a database for storing treatment-related information. Patients with PM from colorectal ovarian, gastric, appendiceal tumors, and other rare peritoneal tumors/metastases from rare tumors are enrolled in the registry. A coordinator updates the disease status of patients on a yearly basis. A private organization maintains the database. A non-disclosure agreement is signed between the company and each surgeon contributing to the registry to maintain confidentiality. For enrolling patients, securing institutional permission depends on the requirement of each institute; patient consent is mandatory. Data entry can be prospective or retrospective. To propose and conduct a study, the approval of a scientific committee linked to the registry is required. The Indian HIPEC registry is a practical database for Indian surgeons. There is no regulatory body that mandates collection and publication of scientific data in India. The onus is on each surgeon to capture valuable information pertaining to these common and rare diseases that could contribute to the existing scientific knowledge and guide the treatment of these patients in the future. The next challenge will be to enter data into the registry.

Management of Borderline Ovarian Tumors-Still a Gray Zone.

Borderline ovarian tumors (BOTs) are a heterogeneous group of non-invasive epithelial ovarian tumors that occur at a younger age, present in early stage, frequently associated with infertility but are easily curable. Although they may have symptomatic long-term recurrences, they have an excellent prognosis in spite of peritoneal spread. Among the epithelial tumors of the ovary, BOTs fall in the spectrum lying between cystadenomas (benign) and cystadenocarcinomas (malignant). Their oncological behavior is more aggressive than benign ovarian tumors but relatively less than that of malignant ovarian tumors. Since the age group affected is usually young females, preservation of fertility is an important aspect of treatment protocol. Although the management of these tumors has been extensively discussed, it still remains a controversial gray zone. In this review, epidemiology, pathogenesis, histologic subtypes, various surgical approaches, follow-up, and management of recurrence have been discussed. Choosing the best treatment still poses a challenge for the treating oncosurgeon.

Resection after neoadjuvant chemotherapy in advanced carcinoma of the gallbladder: a retrospective study.

Although rare over most of the world, Gallbladder cancer is very common in northern india. A delayed presentation, aggressive nature,lack of randomised trials and a poor prognosis have all contributed to the nihilistic halo encircling gallbladder cancer. None of the advances in oncology have been exploited enough to shatter the nihilistic halo. In this background we sought to analyze if the addition of neoadjuvant chemotherapy had any impact on the resectability, overall and disease free survival in patients with advanced carcinoma of the gallbladder. We reviewed the records of all patients who underwent surgery for carcinoma of the gall bladder from 2004 to 2010 at our institute retrospectively. Twenty-one patients received neoadjuvant chemotherapy and subsequently taken up for surgery. Outcome analysis of these 21 patients were done by Kaplan meier method and graphs plotted. Out of the 21 patients who were taken up for surgery after neoadjuvant chemotherapy, fourteen patients underwent R0 resection (Group 1). Seven patients had been rendered inoperable on exploration (Group 2). Thus about 66.67 % of patients deemed resectable after neoadjuvant chemotherapy on imaging underwent R0 resection. The mean overall survival of the group 1 was 42.8 months versus 6.6 months of group 2(Hazard Ratio: 3.42). Neoadjuvant chemotherapy improves resectability in some patients with unresectable gall bladder cancer. Resection after neoadjuvant chemotherapy is feasible and may improve survival in a select group of patients. However randomized studies are required to establish its definitive role.

An Extra-adrenal Pheochromocytoma Presenting as Malignant Hypertension-A Report of two cases.

Malignant hypertension is a complication of hypertension characterized by elevated blood pressure (200mm/140mm Hg), is considered a medical emergency and is rarely secondary to paraganglioma. Malignant hypertension is unique in its relationship to a catecholamine secreting paraganglioma. We present two rare cases of malignant hypertension associated with paraganglioma of tonsil and urinary bladder.

A hairy cell leukaemia variant - a rare case report.

The aim of the article is to present a rare case of Hairy cell leukaemia variant (HCl-V) which is a distinct clinico-pathological entity with intermediate features between classical HCl (HCl-C) and B-cell prolymphocytic leukaemia. It is an uncommon disorder accounting for approximately 0.4% of chronic lymphoid malignancies and 10% of all HCl cases. A 58 year old woman presented with pain abdomen and loss of weight. On examination she had massive splenomegaly. Peripheral smear was reported as chronic lymphoproliferative disorder (? Hairy cell leukemia or splenic lymphoma with villous lymphocytes). On Bone marrow examination, differential diagnosis was given as splenic lymphoma with villous lymphocytes (SLVL) and prolymphocytic variant of Hairy cell leukemia. On flow cytometric analysis, these cells were positive for CD11c, CD19, CD20, and CD22. Based on the clinical, peripheral smear, bone marrow and flow cytometry findings, a diagnosis of hairy cell leukaemia variant was confirmed. The differential diagnosis should always include SLVL, HCL-C and Japanese variant HCL because they have different clinical and biological features, particularly regarding their response to purine analogue-based treatment or splenectomy.

Kras gene mutation and RASSF1A, FHIT and MGMT gene promoter hypermethylation: indicators of tumor staging and metastasis in adenocarcinomatous sporadic colorectal cancer in Indian population.

OBJECTIVE: Colorectal cancer (CRC) development involves underlying modifications at genetic/epigenetic level. This study evaluated the role of Kras gene mutation and RASSF1A, FHIT and MGMT gene promoter hypermethylation together/independently in sporadic CRC in Indian population and correlation with clinicopathological variables of the disease. METHODS: One hundred and twenty four consecutive surgically resected tissues (62 tumor and equal number of normal adjacent controls) of primary sporadic CRC were included and patient details including demographic characteristics, lifestyle/food or drinking habits, clinical and histopathological profiles were recorded. Polymerase chain reaction - Restriction fragment length polymorphism and direct sequencing for Kras gene mutation and Methylation Specific-PCR for RASSF1A, FHIT and MGMT genes was performed. RESULTS: Kras gene mutation at codon 12 & 13 and methylated RASSF1A, FHIT and MGMT gene was observed in 47%, 19%, 47%, 37% and 47% cases, respectively. Alcohol intake and smoking were significantly associated with presence of Kras mutation (codon 12) and MGMT methylation (p-value <0.049). Tumor stage and metastasis correlated with presence of mutant Kras codon 12 (p-values 0.018, 0.044) and methylated RASSF1A (p-values 0.034, 0.044), FHIT (p-values 0.001, 0.047) and MGMT (p-values 0.018, 0.044) genes. Combinatorial effect of gene mutation/methylation was also observed (p-value <0.025). Overall, tumor stage 3, moderately differentiated tumors, presence of lymphatic invasion and absence of metastasis was more frequently observed in tumors with mutated Kras and/or methylated RASSF1A, FHIT and MGMT genes. CONCLUSION: Synergistic interrelationship between these genes in sporadic CRC may be used as diagnostic/prognostic markers in assessing the overall pathological status of CRC.

Neo adjuvant chemo-radiotherapy and rectal cancer: can India follow the West?

AIMS: The management of locally advanced rectal cancer has changed over the years with an emphasis on neoadjuvant chemo radiation therapy (CT-RT) followed by surgery. This study is undertaken to evaluate the efficacy of this treatment in our set of patients with a special focus on the outcome in large circumferential tumors. MATERIALS AND METHODS: The study included patients who underwent neo adjuvant CT-RT between Jan 2006 and Oct 2009 in our institution. They received radical radiotherapy with conventional fractionation to a dose of 45-50 Gy along with continuous two cycles of 5-FU infusion. All patients were assessed at four weeks clinically and by CT scan and underwent surgery if the tumor was resectable followed by adjuvant chemotherapy. RESULTS: A total of 52 patients received the neoadjuvant treatment in form of CT-RT out of which 13 patients had undergone defunctioning colostomy before commencing treatment for severe obstructive symptoms. Only 73% patients underwent surgery in form of AR (anterior resection) or APR (abdominoperineal resection) and adjuvant chemotherapy was delivered in 28 (53.8%) patients only. The patients who underwent diversion colostomy had worse disease-free survival (DFS) as compared to those who received definitive treatment (33% vs. 74.9%, P<0.009). CONCLUSIONS: This study represents Indian experience with standard neoadjuvant chemo radiotherapy followed by surgery in rectal cancer. Large circumferential tumors in our set of patients lead to poor outcome leading to more APR. Also this study supported the need for an abbreviated protocol which can be economically suited and organ preservation protocols have a long way to go.