Impact of delaying surgery after chemoradiation in rectal cancer: outcomes from a tertiary cancer centre in India.

BACKGROUND: Delaying surgery after chemoradiation is one of the strategies for increasing tumor regression in rectal cancer. Tumour regression and PCR are known to have positive impact on survival. METHODS: It's a retrospective study of 161 patients undergoing surgery after neoadjuvant chemoradiation (NCRT) for locally advanced rectal cancer (LARC). Patients were divided into three categories based on the gap between NCRT and surgery, i.e., <8, 8-12 and >12 weeks. Tumor regression grades (TRG), sphincter preservation, post-operative morbidity-mortality and survival were evaluated. RESULTS: Sphincter preservation was significantly less in >12 weeks group compared to the other two groups (P=0.003). Intraoperative blood loss was significantly higher in >12 weeks group compared to 8-12 weeks group (P=0.001).There was no difference in major postoperative morbidity and hospital stay among the groups. There was no significant correlation between delay and TRG (P=0.644). At Median follow up of 49.5 months the projected 3-year overall survival (OS) and disease free survival (DFS) were not significantly different among the 3 groups (OS: 79.5% vs. 83.3% vs. 76.5%; P=0.849 and DFS 50.4% vs. 70.6% vs. 62%; P=0.270 respectively). CONCLUSIONS: Delaying surgery by more than 12 weeks causes more blood loss but no change in morbidity or hospital stay. Increased time interval between radiation and surgery does not improve tumor regression and has no effect on survival.

Radical antegrade modular pancreatosplenectomy for all pancreatic body and tail tumors: rationale and results.

BACKGROUND: Radical antegrade modular pancreatosplenectomy (RAMPS) has been propagated as the standard of care for pancreatic cancers involving the body and tail of the pancreas. This procedure has been shown to have promising results in enhancing the microscopically negative tangential resection margins as well as the lymph node yield. METHODS: This is a retrospective analysis of prospectively maintained database on the resections performed for all pancreatic body and tail tumors at Tata Memorial Centre. RESULTS: Sixty-five patients underwent RAMPS without any perioperative mortality. The various pathologies comprised of adenocarcinoma (41.5%), neuroendocrine tumors (12.3%), solid pseudopapillary epithelial neoplasm (15.3%), cystic neoplasms (15.2%), etc. The R0 resection rate was 87.7%. Among this cohort, 27 patients had pancreatic adenocarcinoma. The 3-year OS and DFS for distal pancreatic cancers were 56% and 38%, respectively, but 3-year OS and DFS for other distal pancreatic tumors were 97% and 73%, respectively. On multivariate analysis, R0 resection significantly improved disease-free survival (p = 0.023) for pancreatic cancer. CONCLUSION: RAMPS procedure aids to achieve high negative tangential margins for all tumors involving the body and tail of the pancreas and not just pancreatic cancer in isolation. Since preoperative histologic diagnosis is not routinely indicated and also a number of other distal pancreatic tumors carry a relatively better prognosis compared with pancreatic cancer, our results provide further evidence that RAMPS should be considered as the procedure of choice for all operable tumors involving body and tail of the pancreas.

Prospective cross-sectional study assessing prevalence and factors affecting trismus after multimodal treatment for oral cancers.

BACKGROUND: Trismus is a common complication following treatment for oral cancers. However, its incidence in site-specific cancers is not adequately studied. The purpose of this study was to assess the prevalence and risk factors associated with trismus in treated patients with oral cancer. METHODS: The maximal mouth opening in treated oral cancers was measured. Logistic regression analysis was performed to find risk factors for developing trismus in the entire cohort and in a subgroup of patients with gingivobuccal complex cancers. RESULTS: A total of 401 patients were enrolled. The prevalence of trismus was 72.8%. On multivariate analysis, adjuvant therapy and submucous fibrosis were independent predictors. Reconstruction and method of reconstruction did not affect trismus. Bialveolar resections had significantly higher incidence of trismus. DISCUSSION: High prevalence of trismus was seen in patients following multimodal therapy for oral cancers. Adequate reconstruction alone may not prevent trismus and aggressive rehabilitation is key to its prevention.

Surgery for brain metastases: An analysis of outcomes and factors affecting survival.

OBJECTIVES: For patients who develop brain metastases from solid tumors, age, KPS, primary tumor status and presence of extracranial metastases have been identified as prognostic factors. However, the factors that affect survival in patients who are deemed fit to undergo resection of brain metastases have not been clearly elucidated hitherto. PATIENTS AND METHODS: This is a retrospective analysis of a prospectively maintained database. All patients who underwent resection of intracranial metastases from solid tumors were included. Various patient, disease and treatment related factors were analyzed to assess their impact on survival. RESULTS: Overall, 124 patients had undergone surgery for brain metastases from various primary sites. The median age and pre-operative performance score were 53 years and 80 respectively. Synchronous metastases were resected in 17.7% of the patients. The postoperative morbidity and mortality rates were 17.7% and 2.4% respectively. Adjuvant whole brain radiation was received by 64 patients. At last follow-up, 8.1% of patients had fresh post-surgical neurologic deficits. The median progression free and overall survival were 6.91 was 8.56 months respectively. CONCLUSIONS: Surgical resection of for brain metastases should be considered in carefully selected patients. Gross total resection and receiving adjuvant whole brain RT significantly improves survival in these patients.

Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy. RESULTS: There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies. CONCLUSION: Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.

Clinical and pathologic response following taxane based neoadjuvant chemotherapy in locally advanced breast cancer patients in a tertiary care centre in India.

BACKGROUND: Neoadjuvant chemotherapy has become the standard recommendation in the management of patients with locally advanced breast cancer. At present anthracycline based regimen such as CAF (cyclophosphamide, adriamycin and 5-FU) is widely used in clinical practice. The introduction of taxanes has revolutionized this field because of superior results. AIMS AND OBJECTIVES: This study is designed to compare the efficacy of paclitaxel plus doxorubicin regimen and CAF (cyclophosphamide, doxorubicin and 5-fluorouracil) regimen as neoadjuvant treatment of locally advanced breast cancer and to compare their toxicity profiles and also to correlate the hormonal receptor status in predicting response to the NACT. MATERIALS AND METHODS: In this prospective study, 101 patients with newly diagnosed locally advanced breast cancer were randomized to receive either CAF or Paclitaxel/adriamycin as NACT for three cycles. The response was assessed objectively using CT scans and applying RECIST criteria. The patients were monitored for hematologic, cardiac and other minor toxicities. RESULTS: There was a significantly increased complete and objective response seen in the AP group when compared to CAF group (24% and 58% in the AP group versus 7.8% and 39.2% in the CAF group, P value 0.0313 for complete response). The pCR rate was also significantly higher in the AP group compared to CAF group. (20.93% versus 4.34%, P value 0.0237). There was no significant difference between the groups with respect to cardiotoxicity and hematotoxicity. Patients with ER negative tumors have responded well to neoadjuvant chemotherapy better than ER positive patients. (Objective response 62.8% vs. 40%, P - 0.0473). CONCLUSIONS: Based on these results, taxane based regimen such as Paclitaxel/adriamycin can be recommended as a first line neoadjuvant regimen in patients with locally advanced breast cancer.

Laparoscopic pancreatoduodenectomy: How far have we come and where are we headed?

Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure has been described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon's experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.