Influence of postoperative complications on relapse-free survival in gastrointestinal malignancies.

OBJECTIVE: A variety of preoperative variables-such as perforation prior to surgery, poor nutritional status, and comorbid conditions such as diabetes-are already known to shorten relapse-free survival in patients with gastrointestinal malignancies. However, the significance of postoperative events in gastrointestinal malignancies is still debated and has not been studied in the population of southern India. METHODS: A retrospective study was conducted at Kidwai Memorial Institute of Oncology, Bangalore, India, from September 2004 to 2006. Patients from a single surgical unit who had undergone surgery with curative intent for gastrointestinal malignancies were evaluated (to maintain uniformity, patients who had undergone palliative surgery were not included in the analysis). We assumed anastomotic leak, delayed wound healing, and postoperative weight loss > 10% as risk factors predictive of poor disease-free survival. These factors were evaluated in all patients, and risk for development of relapse was calculated. RESULTS: A total of 236 patients were evaluated. Baseline parameters were similar in both groups. Compared with patients who developed no postoperative complications, we found that the risk of relapse is 9.8 times greater in patients having anastomotic leak, 8.2 times greater in those with delayed recovery, and 2.3 times greater in those having excessive weight loss. The risk was uniform in all types of gastrointestinal malignancies. CONCLUSION: The results suggest that anastomotic leak, delayed wound healing, and postoperative weight loss in patients with gastrointestinal malignancies confer poor disease-free survival. The presence of these complications warrants closer follow-up and management as appropriate.

Surgical resection for locally invasive renal cell carcinoma: Is it worthwhile?

BACKGROUND: Many patients with renal cell carcinoma (RCC) present with disease involving the adjacent viscera. Although survival in such patients is poor, surgery remains the only proven modality of treatment. We describe our experience with radical nephrectomy for locally invasive RCC over a five-year period. STUDY DESIGN: A retrospective analysis of the records of all patients who had undergone surgery for locally invasive RCC between January 1999 and December 2004 at our institute. MATERIALS AND METHODS: During the study period, 102 patients with RCC underwent surgery at our institute, out of which 18 (17.6%) patients had adjacent organ involvement. The survival and outcomes in terms of symptom relief are described. STATISTICAL ANALYSIS: The survival rates were calculated by the Kaplan-Meier method using EGRET statistical software package. RESULTS: Of the 18 patients, two patients had inoperable disease. Fifteen out of the 18 patients succumbed to their disease after a median period of 7.5 months. Three patients are still alive, having survived for 13, 16 and 25 months. Most patients derived considerable benefit with respect to relief of symptoms, which was long-lasting. CONCLUSION: For selected patients with locally invasive RCC, radical nephrectomy with en bloc resection of involved organs may provide the opportunity for long-term survival. In others, it may provide considerable symptomatic relief.

Childhood hepatic angiosarcoma--a case report.

Hepatic angiosarcoma (HAS) is an extremely rare liver tumor in children. We report a case of childhood HAS in a six year old girl who presented with acute abdominal pain and fever with a mass in epigastrium. Left hepatic lobectomy was performed with a clinical diagnosis of hepatoblastoma. Histopathological examination revealed features typical of hepatic angiosarcoma. The case is presented for its rarity and to discuss the interrelation between infantile hemangioendothelioma (IHE) and HAS.

Mixed exocrine-endocrine pancreatic carcinoma in childhood.

A 7-year-old boy with mixed exocrine-endocrine pancreatic cancer is presented. This may be the second reported case of such a tumor in childhood.

A phase II study of gemcitabine and cisplatin in patients with advanced hepatocellular carcinoma.

The primary objective of this study was to determine the response rates of a combination of gemcitabine and cisplatin in unresectable hepatocellular carcinoma (HCC) in Indian patients. The secondary objectives were to evaluate the toxicity, time to progressive disease and overall survival for this combination. Chemonaive patients with histopathologically proven, bidimensionally measurable, stage Ill or IV unresectable HCC were enrolled into this study. All the patients were required to have a Zubrod's performance status not greater than 2, should not have undergone prior radiotherapy and were required to have adequate major organ function. Patients received gemcitabine (1250 mg/m2 intravenously over 30 to 60 min) on days 1 and 8, and cisplatin (70 mg/m2 intravenously over 2 hours) on day land every 21 days. Response assessment was done by a Computed Tomography scan after every two cycles of chemotherapy. From May to December 1999, 30 patients were enrolled in the study; they were all eligible for efficacy and toxicity analysis. Six (20%) patients achieved a partial response and 13 (43%) patients demonstrated stable disease with 11 (37%) patients showing disease progression. The median time to progression was 18 weeks (range 1 to 74 weeks) and the median duration of response was 13 weeks (range 4 to 68 weeks). The 1-year survival rate was 27% and the median overall survival was 21 weeks (95% CI: 17 to 43 weeks). WHO grade 3 and 4 anemia was seen in 11 (37%) and 2 (7%) patients, respectively. Four (13%) patients each experienced grade 3 and 4 neutropenia and grade 3 and 4 thrombocytopenia was seen in 2 (7%) patients each. Major, non-hematologic toxicities were grade 4 elevated bilirubin levels and grade 3 oral toxicity, in 1 patient (3%) each. This regimen was well tolerated and did show activity in Indian patients with advanced unresectable HCC. There is a need to further evaluate this combination in order to define its role in the treatment of HCC.

Submandibular synovial sarcoma with t(X;18) and synovial sarcoma of the toe with additional cytogenetic abnormalities: presentation of two cases and review of the literature.

We report cytogenetic findings from fine-needle aspiration samples of two synovial sarcoma patients. The cases are of interest because (1) one case is of a rare site (submandibular region) of the head and neck, and (2) the other is a patient with synovial sarcoma of the toe showing additional cytogenetic abnormalities along with t(X;18). The literature of this tumor is reviewed.

Biologic factors and response to radiotherapy in carcinoma of the cervix.

Ionizing radiation has been used to treat cancers for a century. However, radioresistance remains a major problem in the clinic. Recent advances in the understanding of the molecular events that occur following ionizing radiation leading to DNA damage and repair, apoptosis, and cell cycle arrests suggest new ways in which the radiation response might be manipulated. Seventy-eight cases of carcinoma of the cervix of the same stage (II A and B) were analyzed retrospectively. All patients were treated with radiotherapy (RT) with a dose varying from 35 Gy to 50 Gy with 200 cGy per fraction. Subsequent to the completion of radiotherapy, all patients underwent surgery 4-6 weeks later. On histological examination of the surgical specimens, 51% of the cases (40) showed a complete response to therapy with no viable tumor cells. 49% of cases (38) had residual tumors ranging from a small focus to lesions extending through more than half the thickness of the cervical wall. p53 (mutant), bcl-2, p21 and bax proteins were studied on the paraffin sections of the biopsies (pretreatment) of those patients who failed to respond to RT and compared to similar studies on biopsies of patients who had a complete response to RT. In addition, the minichromosome maintenance (MCM) 2 proliferative marker was also done on all cases. Expression of all proteins was done using immunohistochemsitry. In the radioresistant cases, 15% (six cases) showed positivity for bcl-2 and p21, respectively, and 34% (13 cases) showed mutant p53. None of the radiosensitive tumors were positive for the above proteins. 75% of the radiosensitive tumors (30 cases) were positive for the bax antibody, whereas 81% of the radioresistant tumors (31 cases) were negative for bax. The MCM2 proliferative marker was positive in > 80% of cells in 81.5% of radioresistant tumors (31 cases) as compared to < 40% of cells that were positive in 70% of radiosensitive tumors (28 cases). The P-value for the biological markers was calculated using the chi-squared test, and was highly significant (P < 0.01) for all the parameters tested. However, there was no statistical significance by univariate analysis when the dose of radiation was analyzed with respect to the markers and the histological response. There was also no correlation between the radiation response and timing of surgery. The above data strongly suggest that bax, along with proliferative markers, could play a role in determining which tumors are likely to respond to radiation therapy. The presence of bcl-2, p21 and p53 could also be related to radioresistance of the tumors.

Cytogenetic characterization of Ewing tumors using fine needle aspiration samples. a 10-year experience and review of the literature.

Chromosomal analysis was performed in fine needle aspiration samples of 98 primary Ewing tumors (ETs) prior to treatment. Among the 58 (59.18%) successful cultures, t(11;22)(q24;q12) was observed in 87.9% and 6.8% had abnormalities other than t(11;22), viz., del(22)(q12), der(16)t(1;16)(q12;q11), and variant t(8;22)(q24;q12). Involvement of breakpoints 1q21, 1q22, 3p14, 16q22, and 17p13 was also observed. Numerical abnormalities such as trisomies 8 and 12 were found in 29.3% and 20.6% and trisomy 18 in 17.2%. An attempt was made to evaluate the role of these additional changes in the process of tumor development, metastasis, and progression of the disease. This is the largest cytogenetic study on ET from a single center using a simple and reliable technique of fine-needle aspiration culture. The literature on cytogenetics of ET is reviewed.

Neck mestastasis from unknown origin-results of planned primary surgery and post-operative radiation therapy.

Ninety-two patients with metastasis of unknown origin were studied between 1986 and 1997 at Kidwai Memorial Institute of Oncology, India. Treatment included planned primary radical neck dissection followed by radiotherapy. Sixty-seven patients completed our multimodal therapy. Thirty-eight of these patients had a median follow-up pf 35.7 months. Nine patients had a median follow-up of 8.3 months. Twenty patients were lost in follow-up after completing the above protocol. Twenty-five patients did not comply with prescribed therapy. Of the followed up patients 78.9% were disease free. The failure rate was 21%, which comprised of regional failure in 16% and liver metastasis in 5%. Primary manifested at base of tongue in 2 patients. In a third world cancer center like ours, advanced neck disease and unreliable follow-up mandate multimodal therapy to be instituted at the first instance. Manifest primaries should be treated on individual basis.

Sacral chordomas: a 10-year study.

A retrospective analysis of 14 cases of sacral chordoma seen between 1984 and 1993 at the Kidwai Memorial Institute of Oncology is reported. The mean patient age was 54 years, with 13 males and one female. Seventy-one per cent of patients presented with symptoms related to a painful sacral mass. Eight patients underwent radical surgery and two had adjuvant radiotherapy. One patient had a partial tumour resection. Three patients received radical radiotherapy. Two patients were offered only pain relief medication. The median follow-up was 33 months. The actuarial overall survival (OS) at 5 years was 48%. In the 12 patients in whom curative therapy was attempted, the 5-year OS was 56% and progression-free survival was 36%. Four patients developed local recurrence and three developed distant metastasis.

Importance of anatomical subsite in correlating risk factors in cancer of the oesophagus--report of a case--control study.

In Bangalore, cancer of the oesophagus is the third most common cancer in males and fourth most common in females with average annual age-adjusted incidence rates of 8.2 and 8.9 per 100,000 respectively. A case-control investigation of cancer of the oesophagus was conducted based on the Population-based cancer registry, Bangalore, India. Three hundred and forty-three cases of cancer of the oesophagus were age and sex matched with twice the number of controls from the same area, but with no evidence of cancer. Chewing with or without tobacco was a significant risk factor. In both sexes chewing was not a risk factor for cancer of the upper third of the oesophagus. Among males, non-tobacco chewing was a significant risk factor for the middle third but not for the other two segments and tobacco chewing was a significant risk factor for the lower third of the oesophagus, but not for the other two segments. Bidi smoking in males was a significant risk factor for all three segments being highest for the upper third, less for the middle third and still less for the lower third. The risk of oesophageal cancer associated with alcohol drinking was significant only for the middle third.

Hemangiopericytoma of bone--a case report.

A case of low grade hemangiopericytoma of three years duration occurring in the upper end of the femur of a 70 year old man is described. Radiologically, the upper third of the right femur showed a destructive expansile osteolytic lesion with soft tissue extension. The tumour was partially encapsulated. Mitoses were 0-1 per 10 high power fields, suggesting the low grade malignant nature of the lesion. It is felt that all hemangiopericytomas occurring in bone should be considered biologically malignant.

Unusual splenic metastasis from oesophageal cancer.

The most common visceral metastasis from oesophageal carcinomas are lungs and liver. A case of splenic metastasis from a squamous carcinoma of oesophagus is reported. To our knowledge, splenic metastasis without any nodal disease has not been described previously. The pattern of reported metastasis is summarised.

Neoadjuvant Cis-DDP in esophageal cancers: an experience at a regional cancer centre, India.

We are analysing the results of 80 patients who underwent surgery during 1983-84 for esophageal cancer. Forty patients who received pre-operative single agent Cis-DDP were grouped under "A" and 40 patients who went for surgery directly were grouped under "B". Twenty-two patients (55%) of Group A showed tumor necrosis. Both groups underwent resection and hand-sewn anastamosis of the esophagus. There were 10 post-operative deaths among 80 resected cases, 9 of them being from anastomatic leak. Cis-DDP has induced negligible side effects. A comparatively high survival rate during early years in patients who responded to Cis-DDP suggests that neoadjuvant chemotherapy might be of value.