Perioperative complications of esophagectomy: Postneoadjuvant treatment versus primary surgery - Our experience and review of literature.

AIMS: : To compare perioperative complications in esophagectomy after neoadjuvant therapy v/s primary surgery. SETTINGS AND DESIGN: : Retrospective analysis of perioperative complications in a prospectively maintained data base of patients who underwent esophagectomy as Primary surgery or after neoadjuvant therapy was done. METHODS AND MATERIAL: : 238 cases of esophagectomies performed for esophageal carcinoma were analysed and compared, out of which 125(52.5%) were given neoadjuvant therapy followed by surgery and 113(47.5%) underwent primary surgery. Surgical procedure was standard for both the groups. All the cases were analysed for perioperative complications. STATISTICAL ANALYSIS USED: : Data was analysed using Open Epi soft ware. Association between the two study group was assessed with Chi square test. RESULTS: : On comparison, both the groups were comparable in demographic profile and type of surgery performed. However, tumour stage was higher for cases who received neoadjuvant therapy as expected. On analysis there was no significant difference in overall morbidity and 30 days mortality. CONCLUSIONS: : Neoadjuvant Chemo/chemoradiotherapy is a feasible option in esophageal carcinoma without increase in incidence of peri operative morbidity or mortality.

Penile metastasis from esophageal squamous carcinoma after curative resection.

The penis is an uncommon site of metastasis; with only about 300 cases reported in literature. The majority (75%) of primary tumors are located in the pelvis, and they arise from the genitourinary tract and rectum. We report on a patient with esophageal squamous carcinoma who underwent a curative resection and later developed metastatic nodules over the penis and perineum. We believe this is the first instance of this unusual presentation. He was offered palliation with weekly taxanes and had symptomatic relief with this regimen.

Cervical lymph node metastases of squamous cell carcinoma from an unknown primary: outcomes and patterns of failure.

CONTEXT: Management of cervical lymph nodes metastases of squamous cell carcinoma (SCC) from primary of unknown origin (PUO) is contentious and there is insignificant data from India on this subject. AIMS: To present experience of management of these patients treated with curative intent at a single institution. SETTINGS AND DESIGN: Retrospective study of patients treated between 1989-1994 in a tertiary referral cancer centre. MATERIALS AND METHODS: Eighty-nine patients were evaluated in the study period and their survival compared with patients with common sites of primary in the head and neck with comparable node stage. STATISTICAL ANALYSIS USED: Kaplan-Meier method. RESULTS: The clinical stage of the neck nodes at presentation was N1 in 11%, N2a in 28.5%, N2b in 22.5%, N3 in 35% and Nx in 3.4% patients. All patients underwent surgery and 70 patients received more than 40Gy postoperative radiotherapy. Twenty-nine (32.6%) patients had relapse of which 19 (21%) were in the neck. Postoperative radiotherapy did not influence the neck relapse (p=0.72). Primary was detected in 13 patients (14.6%) on subsequent follow up. The overall five and eight-years survival was 55% and 51% respectively. The overall five-year survival was better compared to patients with known primary with comparable node stage. CONCLUSIONS: Patients with cervical lymph nodes metastases of SCC from PUO have reasonable survival and low rate of development of subsequent primary when treated with surgery and radiotherapy. The overall survival is comparable to that of patients with known primary and hence an attempt at cure should always be made.

Case report: Second primary small cell carcinoma of the trachea in a breast cancer survivor: a case report and literature review.

Small cell carcinoma of the trachea is a rare entity and only a few cases have been described, none as a second malignant neoplasm. This is the first report of a metachronous second primary of the trachea with small cell histology in a breast cancer survivor. A 25-year-old woman was diagnosed initially with an infiltrating ductal carcinoma of the breast, and was treated with modified radical mastectomy followed by adjuvant chemo-radiotherapy. 10 years later, she presented with breathlessness and central airway obstruction. Bronchoscopy revealed an intraluminal lesion in the proximal trachea, which was reported as small cell carcinoma on biopsy. There was no evidence of loco-regional recurrence of the previously treated breast cancer. Whole-body positron emission tomography did not show any distant metastases. As it was a small cell carcinoma, she was treated with concurrent chemo-radiotherapy and remains loco-regionally controlled. Decision-making in such instances should take into account prior treatment and needs to be individualized. There is a need for increased awareness amongst primary care physicians regarding second malignant neoplasms in the long-term follow-up of breast cancer patients treated with radiation and chemotherapeutic agents that have carcinogenic potential.

Ectopic thyroid cancer.

Ectopic thyroid tissue may be encountered anywhere from the foramen caecum to the lower neck. It is rarely seen in the mediastinum. True malignant transformation in ectopic thyroid tissue is extremely rare. Such a malignancy is virtually always diagnosed after surgical excision of the lesion at pathological examination. We report on an extremely rare case of true mediastinal thyroid cancer in a 45-year-old woman. The clinicopathologic features and diagnosis of the lesion, with regard to its mediastinal location are discussed.

Injury of an aberrant subclavian artery: a rare complication of video assisted thoracoscopic esophagectomy.

An aberrant right subclavian artery is an uncommon anomaly. When associated with esophageal cancer, it can cause diagnostic confusion as the symptoms are similar. If unrecognized and injured during esophageal surgery, it can lead to disastrous complications. We report a patient in whom this aberrant artery was injured during a thoracoscopic mobilization of the esophagus. The embryological and radiologic aspects of this anomaly and its clinical significance are discussed. Pre-operative diagnosis will require a high index of suspicion, as the clinical and radiological features are not specific. If injury occurs, an immediate vascular reconstruction will prevent limb ischemia and hence knowledge of this entity is of utmost importance.

Two- vs three-drug combination chemotherapy in advanced or recurrent head and neck cancer: a single institution experience of 361 patients.

Head and neck squamous cancer is a major concern in India. The proportion of advanced cases is significantly high, and these patients have dismal survival prospects despite aggressive therapy. Often surgical resection and/or radiotherapy are not feasible in these patients. Hence, we decided to explore the option of neoadjuvant chemotherapy using effective agents like ifosfamide and paclitaxel in combination with cisplatin in these patients. A total of 361 patients were evaluable at the end of study. Of these, 207 had received ifosfamide and cisplatin and 154 had received taxanes (paclitaxel or docetaxel) in addition to ifosfamide and cisplatin. The ifosfamide-cisplatin group had an overall response rate of 66.67% (CR, 16.42%; PR, 50.24%) and the median duration of response was 5.5 mo; whereas the group in which taxanes were added, showed an overall response rate of 73.37% (CR, 7.79%; PR, 65.58%) with a median duration of response of 10 mo. The toxicity in both the groups was acceptable and there was no mortality. We conclude that taxane-based combinations have a significant activity in advanced head and neck squamous cancer and warrant further studies.

Upfront submandibular salivary gland transfer in pharyngeal cancers.

Head and neck irradiation results in salivary dysfunction and subsequent xerostomia. Twenty two patients with squamous cancer of oropharynx or hypopharynx underwent contralateral submandibular salivary gland transfer (SMSGT) to submental triangle to shield it from subsequent radiotherapy. Resting salivary outputs of transferred and untransferred gland (control) were measured before and after SMSGT and following radiotherapy, by cannulating individual submandibular duct. They were compared by paired samples t-test. Following radiation therapy transferred gland retained 73% and untransferred gland (control) retained 27% of baseline salivary output. This significant difference in post-radiation salivary outputs suggests preservation of function of transferred salivary gland.

Radical radiation vs surgery plus post-operative radiation in advanced (resectable) supraglottic larynx and pyriform sinus cancers: a prospective randomized study.

AIM: Survival in head and neck cancers reflect loco-regional control. With an aim of organ and function preservation the present study was undertaken to compare local failure and survivals. MATERIAL AND METHODS: Between August 1991-December 1995, 72 patients with resectable advanced supraglottic cancers, were randomized to radical surgery followed by post-operative radiation therapy (Sx+PORT) (Arm I) or radical radiation therapy followed by salvage surgery (RRT+/-SSx) (Arm II). RESULTS: Sixty-four of 72 patients were evaluable, 55 were T3 (86%) and 9 were T4 (14%) tumors. In Arm I (n=35) with a mean follow-up of 24 months (2-86 months), 21 patients were alive without disease. Six patients had recurrence, one each at local and tracheostomy stoma, four had nodal recurrence only, and two developed 2nd primary in soft palate/tonsil and parotid at 15 and 18 months respectively. In Arm II (n=29), with a mean follow-up of 24 months (3-81 months), 14 patients were alive without disease. Thirteen patients had recurrence, eight had local (one patient had persistent disease), two nodal only, three loco-regional and two patients developed distant metastasis (lung). One out of eight local recurrence and 2/2 nodal recurrences were salvaged with Sx. There was a significant difference in disease-free survival between the two treatment arms, DFS (5 years) of 70% in Arm I vs 50% in Arm II (p=0.04), but did not have any impact on overall survival OAS (5 years); 73% vs 77% (p=0.79). Voice/laryngeal preservation was possible in 18/29 patients (62%) treated with RRT+/- Sx, without significantly affecting the OAS. "Pathological upstaging" was another significant finding seen in 64% of clinical T3 after radical surgery. CONCLUSION: RRT+/-SSx can be a feasible option in low volume, favourable resectable stage III and IV supraglottic lesions for better quality of life.

Neoadjuvant chemotherapy with ifosfamide and cisplatin combination in advanced head and neck cancer: a retrospective analysis of 519 patients: a single institution experience.

Advanced head and neck cancer is a major therapeutic problem in India. Ifosfamide has shown significant activity as a single agent in head and neck squamous carcinoma. In this study, we present our experience with two cycles of ifosfamide and cisplatin in the neoadjuvant setting given to a total of 519 patients. The complete response rate was 20% and the overall response rate was 80%. The treatment was well tolerated, there was no need for dose reduction, and there were no life-threatening side effects. We feel that this high response rate is sufficient to warrant more studies using ifosfamide-based combinations in a neoadjuvant setting for squamous carcinoma of the head and neck.

Evidence-based protocols for the management of well-differentiated carcinomas of the thyroid.

OBJECTIVES: In recent years, well-differentiated carcinomas of the thyroid have been stratified into low-risk and high-risk groups. The pattern of thyroid cancer in India is different from that seen in the West. Moreover, patients present with more advanced stages of the disease. Our aim was to develop protocols for the management of well-differentiated thyroid cancer, based on the analysis of our data and our experience. METHODS: Cases of thyroid carcinoma, which were surgically treated at the Tata Memorial Hospital during 1970-5, were studied. The survival curves were plotted according to the Kaplan-Meier method. Univariate analysis was done using the log rank test. The prognostic factors analyzed were age, sex, tumour size, extra-thyroid extension, distant metastases and lymph node metastases. Multivariate analysis using the Cox regression model was performed. Analyses were separate for follicular and papillary carcinomas. RESULTS: Four hundred and seventeen cases were entered in the study, of which 198 were follicular and 219 were papillary. Based on the evidence derived from this study, we stratified our cases into low- and high-risk groups. The low-risk group consisted of patients below 40 years of age, nodules smaller than 5 cm, absence of extra-thyroidal spread and absence of distant metastases. For follicular carcinoma, the low-risk group had 100% survival at 15 years, compared with 40% for the high-risk group. (p < 0.001). For papillary carcinomas, the survival at 15 years was 95% for the low-risk group and 40% for the high-risk group (p < 0.001). CONCLUSIONS: We recommend lobectomy for the low-risk group, and total thyroidectomy for the high-risk group and for cases with lymph node metastases. In the latter, total thyroidectomy facilitates the use of 131I.

Prognostic factors in head and neck soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas of head and neck constitute a heterogeneous group of rare malignant tumors occurring at rare sites. The purpose of this retrospective study is to evaluate the pathologic features, treatment modalities, outcome, patterns of failure, survival, and other prognostic factors. METHODS: The medical records of 72 patients whose tumors were diagnosed as head and neck sarcomas, treated at Tata Memorial Center between 1981 to 1995 were reviewed. Potential prognostic factors including age, gender, tumor size, histology, grade, and adjuvant treatment were evaluated. RESULTS: The overall and disease free survival at 5 years was 60% and 45%, respectively. The median survival and follow-up was 76 and 38 months, respectively. Thirty-two patients (44.4%) developed recurrence of which 13 patients were salvaged. The univariate and multivariate analysis showed tumor size and grade as important prognostic factors for the survival. CONCLUSIONS: Tumor size greater than 5 cm and high grade tumors were important prognostic factors for survival. Every effort should be made for early diagnosis and wide surgical excision. For localized recurrent tumors without evidence of distant metastasis, surgery should be attempted whenever possible. High rates of locoregional failure in head and neck area indicate the need for improved treatment strategies.

Complications following gastric transposition after total laryngo-pharyngectomy.

AIMS: To investigate restoration of the pharynx after total laryngo-pharyngectomy (TLP), one of the major problems in head and neck surgery. METHODS: A retrospective analysis of 60 patients undergoing total laryngo-pharyngectomy with gastric transposition was performed between June 1991 and June 1996. The analysis focused on morbidity, mortality and long-term function following gastric transposition. RESULTS: The post-operative mortality was 8.3% and the peri-operative morbidity 31.2%. The average hospital stay was 15 days. Immediate restoration of swallowing was achieved in 83% of patients. CONCLUSIONS: Gastric transposition after total laryngo-pharyngectomy is a safe procedure and can be performed with low mortality, acceptable morbidity and good long-term function.

Metastasis of osteosarcoma to the maxilla--a case report.

Secondary osteosarcomas of the maxilla/premaxilla are extremely rare. We describe a case of a 24-year-old man with a metastasis of osteosarcoma to the premaxilla. The patient had undergone hip disarticulation followed by adria based chemotherapy for chondroblastic osteosarcoma of the proximal right femur ten years ago. The metastatic work up did not show liver or lung metastasis. The patient underwent premaxillectomy in February 1999. The histopathology revealed a chondroblatic osteosarcoma consistent with metastasis in the clinical setting. The patient was disease free at the end of five months.

Undifferentiated embryonal sarcoma of the liver in childhood.

Primary undifferentiated embryonal of the liver in children is a rare neoplasm with dismal prognosis. Surgery is the treatment of choice. Adjuvant chemotherapy may prove useful in improving the prognosis of these tumours. We report two cases of Primary undifferentiated embryonal sarcoma of the liver.

Primary germ cell tumours of the mediastinum.

Twenty nine cases of primary mediastinal germ cell tumours (MGCT) were seen at the Tata Memorial Hospital over a 16--year period (1974-1989). There were 5 benign MGCT occurring predominantly in females (80%), with these patients having an excellent result after surgery with all patients disease free at an median follow-up of 27 months. Malignant MGCT occurred only in males and demonstrated wide variation in response to treatment depending upon whether the tumour was seminomatous or non-seminomatous. There were 11 Seminomas, 5 Embryonal carcinomas, 5 Endodermal sinus tumours and 3 Teratocarcinomas. The diagnosis was established by surgical exploration or by biopsy of a lymph node or chest wall nodule in 20 patients. Four patients had needle biopsy. Seminomatous MGCT received radiotherapy as their main treatment modality and did well with 75% of the patients alive without disease at an average follow up of 33 months. The non-seminomatous MGCT could be divided into two groups. The mean survival for patients receiving cisplatinum based chemotherapy was 14 months as compared to the group not receiving such therapy where the survival was only 5.3 months. However, because of the advanced disease at presentation even in the group receiving cisplatinum chemotherapy, a long term complete response rate of only 20% could be achieved.