Parapharyngeal Space Tumors-What Lies in This Hidden Space?

The parapharyngeal or the lateral pharyngeal space is a potential anatomical space in the lateral neck extending from skull base to the hyoid bone. The fascial attachment between the styloid process and tensor veli palatini muscle divides this space into two compartments - pre styloid and post styloid. Primary tumors arising from this hidden space are quite rare and demand reasonable doubts and advanced surgical expertise in management. We describe our experience in managing these tumors and the varied surgical approaches.

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.

Laparoscopic approach for malignant retrorectal tumour: Better vision and lesser morbidity.

The retrorectal tumours are removed by open approaches according to the type, location and size of the lesion. Malignant tumours are mostly operated by open approach owing to the fear of spillage and inability to obtain safe oncological margin. We present our recent experience of laparoscopy for a malignant retrorectal tumour. An 11 cm pre-sacral mass causing erosion of sacrum was operated with a combined approach. Transsacral approach followed laparoscopic mobilisation with the patient in prone jackknife position. Wide excision with sacrectomy was done with adequate margin. Post-operative histopathology showed dedifferentiated chordoma for which adjuvant radiotherapy was given. Laparoscopic approach provides a feasible and oncological safe alternative to the conventional approaches, especially in malignant tumour with advantages of better visualisation, minimal operative morbidity, lesser post-operative pain and shorter hospital stay. However, the surgical approach should be tailored to each patient according to patient factors, tumour characteristics and surgeon's expertise.

Comparative Study of Laparoscopic versus Conventional Open Surgical Staging Procedure for Endometrial Cancer: Our Institutional Experience.

OBJECTIVE: The aim of this study was to compare laparoscopic surgical staging of endometrial cancer with conventional open methods. MATERIALS AND METHODS: The retrospective data were collected from 90 endometrial cancer patients who were operated between 2013 and 2018 in our government institution. The safety and morbidity of the two groups were compared based on mean operative time, blood loss, intraoperative complications, postoperative complication, etc., and the results were analyzed. Statistical analysis was performed using IBM SPSS statistics version 20. Clinical and pathologic factors were compared between two groups with Fisher's exact test and Student's t-test for data analysis. The survival data were analyzed using Kaplan-Meier survival curves. P < 0.05 was considered statistically significant. RESULTS: Thirty-two patients underwent laparoscopic staging, 45 underwent laparotomy, and 13 cases lap converted to open surgery. The mean operative time for the laparoscopic procedure was lower than the open procedure (P = 0.001). The mean hospital stay of patients who underwent laparoscopic staging was around 7.1 days significantly less compared to the laparotomy group. Intraoperative blood loss of patients undergoing laparoscopic surgery was significantly less than that of the laparotomy group (P = 0.015). There was no statistically significant difference in nodal retrieval between laparotomy and laparoscopy group (P = 0.172). The mean duration of hospitalization was statistically significantly greater in the laparotomy group than the laparoscopic group (13 and 7 days, P < 0.001). Based on the Kaplan-Meier survival curve, there was no difference in survival rates between the groups. Median follow-up duration was 32 months. CONCLUSION: Laparoscopic surgical staging is oncologically safe for the management of endometrial cancer with acceptable morbidity compared to the open approach with far less blood loss and shorter postoperative stay.

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.

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.

Treatment Outcome of Carcinoma Vulva Ten-Year Experience from a Tertiary Cancer Centre in South India.

BACKGROUND: Carcinoma vulva is a rare disease accounting for 1.3% of all gynaecological malignancies. The present study is a 10-year retrospective review of our experience of the surgical options, morbidity, failure pattern, and survival for invasive carcinoma vulva. MATERIALS AND METHODS: Retrospective analysis of case records of 39 patients who underwent surgery for invasive vulval cancer between 2004 and 2013 in the Department of Surgical Oncology at the Government Royapettah Hospital, Chennai. RESULTS: The median age was 55 years. Radical vulvectomy was the preferred surgery. 31 patients underwent lymphadenectomy. Seroma formation and groin skin necrosis were the most common postoperative complications. With a median follow-up of 32 months, 8 patients (20.5%) developed recurrence (systemic = 1, regional = 4, and local = 3). The estimated 5-year disease-free survival (DFS) was 65.4% and the overall survival (OS) was 85.1%. On univariate analysis, stage and lymph node involvement significantly affected OS. Nodal involvement with extracapsular spread (ECS) significantly affected both DFS and OS. CONCLUSION: The treatment of carcinoma vulva should be individualized with multidisciplinary cooperation. The paucity of data, especially from India, necessitates the need for more studies, preferably multicentric, keeping in mind the low prevalence.

Primary lesser sac myxoid liposarcoma: A case report.

INTRODUCTION: Lesser sac pathological entities are uncommon. Most of these are tumors and are generally misdiagnosed as retroperitoneal lesions. CASE REPORT: A 62year old male with past history of treated hypopharyngeal cancer presented with progressive abdominal distension. Physical examination revealed a midline intra abdominal mass in the epigastrium and umbilical region. Radiological investigations were suggestive of a retroperitoneal tumor,an image guided biopsy was reported as atypical lipoma. Surgical exploration confirmed a large multi lobulated tumor arising primarily from the lesser sac, post operative histopathological examination confirmed a myxoid liposarcoma. DISCUSSION: Primary lesser sac tumors are rare, a literature review of primary lesser sac tumors with particular reference to myxoid liposarcoma is presented. CONCLUSION: Primary lesser sac liposarcomas are rare neoplasms. The myxoid variant is unique for its peculiar biological behavior, in its sensitivity to chemotherapy and radiotherapy and for the presence of specific cytogenetic marker.

A prospective study on sentinel lymph node biopsy in early oral cancers using methylene blue dye alone.

Sentinel Lymph Node (SLN) biopsy using a combination of radioisotopes and blue dyes have a good accuracy rate in predicting subclinical neck nodal metastases in head and neck cancers. However, the limited availability of lymphoscintigraphy facilities in India requires exploration of alternative methods of SLN detection. We evaluated the feasibility of using methylene blue dye alone in detecting SLN in cN0 early oral cancers. 32 patients with cN0 early (T1, T2) oral squamous cell cancers underwent SLN biopsy using peri tumoural methylene blue dye injection. Blue dye stained (SLN) nodes were sent for frozen section analyses. Patients who had microscopic metastases in SLN underwent modified radical neck dissections and the rest underwent selective neck dissections. Paraffin sections and IHC studies were done on all nodes. SLN was identified in 29 patients (Identification rate = 90.6 %) of which SLN was positive for metastases on frozen section in 5 patients. The sensitivity, specificity and NPV of SLN with frozen section were 80 %, 95.8 % and 95.8 % respectively. IHC with cytokeratins increased the sensitivity (100 %) and NPV (100 %) at the loss of specificity (87.5 %). Methylene blue dye alone can be successfully used for SLN identification in early oral cancers with a good accuracy and sensitivity. This method will be of use especially in resource limited countries and centres where nuclear medicine facilities are not widely available. However, it has to be validated by larger randomised multi institutional trials for wider applicability. Immunohistochemistry increases the sensitivity and negative predictive value of SLN but its applicability in real time decision making is limited.

Unusual late complication following anterior pelvic exenteration and ileal conduit.

We report an unusual case of Conduit Perineal Fistula following Anterior Pelvic Exenteration and Ileal conduit, performed for cancer cervix in a patient who had post radiotherapy residual disease. Revision surgery and redo conduit with transverse colon was done. Patient tolerated the procedure well and postoperative period was uneventful. Patient was subsequently disease free for 27 months. She developed a pelvic recurrence and lived with the disease for another 36 months and was then lost to follow up.