Role of 18F-FDG PET/CT in Guiding Surgical Management of Clinically Node Negative Neck (cN0) in Carcinoma Oral Cavity.

Conventional staging paradigm with clinical examination or imaging invariably leads to underestimation of occult metastatic neck disease in oral cavity carcinoma. The advantage of 18F-FDG PET/CT is in its ability to identify lymph nodes without morphological changes yet harboring occult metastases. We present findings of our study to evaluate diagnostic accuracy of 18F-FDG PET/CT, in detecting occult cervical lymph node metastasis in carcinoma oral cavity. In a single institution prospective study, 51 consecutive patients with histologically proven (cT1/T2) oral cavity carcinoma and clinically node negative neck (cNo), underwent 18F-FDG PET/CT before elective neck dissection of 58 neck sides. 18F-FDG PET/CT findings were compared with histopathology of dissected nodes, to calculate diagnostic accuracy. 18F-FDG PET/CT correctly characterized the occult lymph node metastasis status (true positive + true negative) in 51 of 58 neck sides, yielding diagnostic accuracy of 87.93%. Sensitivity of 18F-FDG PET/CT was 90% and specificity was 87.5%. While a positive 18F-FDG PET/CT accurately predicted the disease in only 60% (positive predictive value), a negative 18F-FDG PET/CT reasonably ruled out occult metastases in 97.67% (negative predictive value). If a decision regarding the need for neck dissection had been based solely on 18F-FDG PET/CT, the number of neck dissections would have been reduced by 74.13%. Based on diagnostic accuracy and high negative predictive value, incorporating 18F-FDG PET/CT in preoperative staging paradigm of cT1/T2 carcinoma oral cavity will guide in selection of patients in which cN0 neck can be safely observed.

Craniocerebral missile injuries in a combat zone: spectrum of injuries and lessons learnt.

BACKGROUND: High-velocity missile injuries are commonly encountered in war or war-like situations. Aggressive resuscitation, early evacuation to neurosurgical center, and application of neurosurgical principles remain tenets of success. METHODS: The spectrum of injuries and clinical profile of 14 such cases with craniocerebral missile injuries managed at our center in the northern sector were included. Site of injury, GCS at presentation, associated injuries, surgical intervention, duration of hospitalization, and recovery of the patient were analyzed. RESULTS: Five patients had sustained gunshot wounds, and nine patients had sustained shrapnel injuries. Thirteen patients were deeply comatose, and one patient was conscious. The entry wound was in frontal lobe in eight patients, and in four patients, it was in the faciocranial area. Ten patients had Glasgow Coma Scale (GCS) less than 8 at presentation. Surgical intervention was required in 13 patients, including 11 decompressive craniectomies and anterior skull base repair in four patients with faciocranial entry wound. One patient expired during initial resuscitation, and one patient died in the postoperative period. Location of injury was the single most important determinant of outcome. CONCLUSION: An early decompressive craniectomy provides a reasonable chance of recovery. Aggressive debridement involving track explorations, lobectomies, or removal of retained shrapnels is not beneficial. Injuries to the skull base and violation of sinus spaces predispose these patients to cerebrospinal fluid leaks and infective sequelae. All these patients require aggressive postoperative intensive care and rehabilitation.

Refractory hypotension in post-operative setting with raised intracranial pressure: insula at play?

Raised Intra-Cranial Pressure causes hypertension. We report a 75 years old lady with large Middle Cerebral Artery bifurcation aneurysm that was operated on. Post-operatively she had a progressive hypotension that was refractory to inotropes and became life threatening. There was subgaleal, extradural and subdural collection of Cerebro-Spinal Fluid. Drainage of this collection led to immediate complete recovery from hypotension, normalization of tachycardia and improvement in sensorium within 4 hours. Raised Intra-Cranial Pressure can manifest with hypotension and tachycardia if the right insula has been exposed. Removal of the irritant can lead to rapid and complete recovery.

Patterns of Presentation, Treatment, and Survival Rates of Gallbladder Cancer: a Prospective Study at a Tertiary Care Centre.

BACKGROUND: India has high incidence of gallbladder carcinoma with regional variation in incidence, the highest in Northern India. This study examines the patterns of presentation, treatment strategies, and survival rate of all patients with gallbladder cancer (GBC) evaluated at our tertiary academic hospital over a period of 2 years. METHODS: All patients presented to our institute with established tissue diagnosis of carcinoma gallbladder were accrued in our study over a time period of 2 years. Presentation, treatment modalities, and survival rates were analyzed. RESULTS: One hundred six patients were included: 80 females and 26 males (F: M = 3:1). Median age was 60 years. Eighty patients (75%) had gallstones and 20 patients (21%) had typical history of chronic cholecystitis. The common symptom and sign at presentation were pain in the right upper abdomen (81%) and lump abdomen (49%), respectively. Overall resectability rate was 19.8% (21/106). Eighty-five patients were unresectable or metastatic and treated with palliative intent. Stagewise distribution at diagnosis was stage I (0%), stage II (4%), stage IIIA (10%), stage IIIB (8%), stage IVA (17%), and stage IVB (61%). Estimated 1-year survival for stages II, IIIA, IIIB, IVA, and IVB was 100, 76, 47.4, 26, and 10.6%, respectively. Significant difference in OS was observed among different stages of GBC (p value <0.001). CONCLUSION: If proper investigations are done, radical surgery including multi-organ resection can be curative with acceptable morbidity and mortality. Stage at presentation and ability to perform curative resection are the most important prognostic factors predicting survival. Palliative chemotherapy should be considered for metastatic GBC.

Chemotherapy Compared with Best Supportive Care for Metastatic/Unresectable Gallbladder Cancer: a Non-randomized Prospective Cohort Study.

Gallbladder cancer (GBC) is the most common biliary tract malignancy. Incidence varies widely with geographic regions, with northern India being the endemic area for GBC. Curative surgery offers the only chance of cure, but most of patients present with unresectable or metastatic disease and are candidates for palliative treatment only. This study was designed to evaluate efficacy of chemotherapy over best supportive care in unresectable/metastatic GBC. Patients with unresectable/metastatic GBC with proven tissue diagnosis were enrolled for single institution non-randomized prospective cohort study between May 2012 and April 2014. A total of 65 patients received palliative chemotherapy; either combination chemotherapy (n = 59) or single agent chemotherapy (n = 6). Combination chemotherapy regimen were either three weekly Gemcitabine-Cisplatin (n = 45) or Gemcitabine-Oxaliplatin (n = 14) for a maximum of six cycles. Twenty patients, either unfit for chemotherapy or unwilling for the same were advised best supportive care (BSC). The overall response rate to chemotherapy was 34 %. Median survival for chemotherapy group and BSC group were 35.6 and 13 weeks, respectively (p value < 0.001). Median OS for combination chemotherapy (n = 59) and single agent chemotherapy (n = 6) were 37 and 26.7 weeks, respectively (p value- 0.002). Median PFS for combination chemotherapy and single agent chemotherapy were 26 and 15 weeks, respectively (p value-0.012). The results of this study are quite encouraging and support use of chemotherapy for unresectable GBC patients over best supportive care, and that gemcitabine based combination chemotherapy may be a better choice for response rates, OS, and PFS.

Suture granuloma: a rare differential diagnosis of residual/recurrent gastrointestinal stromal tumor of stomach.

In the present era of modern surgical practice, the incidence of intra-abdominal suture granuloma is extremely rare with reduced use of non-absorbable silk sutures and even rarer following laparoscopic procedures. We report herein a case of silk granuloma presenting as large submucosal polypoidal lesion in a recently operated case of gastrointestinal stromal tumor (GIST) of stomach. Though endoscopic biopsy showed chronic non-specific gastritis with no evidence of malignancy, our patient underwent excision of lesion due to high likelihood of neoplastic lesion suggested by radiological evaluation and recent history of surgery for GIST but histopathology surprisingly showed Giant cell silk granuloma. In summary, the possibility of suture granulomas should always be considered while evaluating postoperative CT scan/PET scan for a mass lesion at operated site, particularly in patients who have undergone surgery with non-absorbable silk sutures.

Aggressive Surgical Approach for Gallbladder Cancer: a Single-Center Experience from Northern India.

BACKGROUND: Gallbladder cancer (GBC) is an aggressive disease with dismal results of surgical treatment mainly because of advanced stage at presentation. The objective of this study was to investigate whether aggressive surgical treatment can be associated with reasonable survival for patients with GBC at acceptable morbidity and mortality. METHODS: A total of 113 patients with proven or presumptive diagnosis of GBC were recruited prospectively over a period of 2 years and evaluated for diagnosis and staging by appropriate investigations. Seven out of 113 patients were found to have benign pathology either intraoperatively or on histopathological examination hence excluded from follow-up and survival analysis. Out of 32 potentially resectable patients, only 21 patients could finally be resected with curative intent. Patients found unresectable/metastatic disease intraoperatively (n = 11) were treated with palliative chemotherapy if eligible for the same. Short-term morbidity, perioperative mortality, disease-free survival (DFS), and median overall survival (OS) of surgically resected patients were analyzed. Median OS of resected patients was compared with that of unresectable patients. RESULTS: Overall resectability rate in this study cohort was 19.8 % (21/106). Overall mortality was 4.7 % and morbidity was 42.8 %. Stage distribution of resected patients was as follows: stage II (3), stage IIIA (9), stage IIIB (8), and stage IVA (1). DFS at 12 and 18 months was found to be 82.5 and 73.3 %, respectively. Mean DFS was 19.9 months (SE 1.42, 95 % CI). Mean OS for resected patients was 21 months and that for unresectable patients was 11.3 months only. Both groups were compared using log rank (Mantel-cox) test and statistically significant difference in OS was observed (p value <0.0001). CONCLUSION: Since curative resection is the only chance of cure, aggressive surgical approach adopted by us is justified with acceptable mortality and morbidity and encouraging overall survival.

Ectopic thymoma with pure red cell aplasia--ambiguity with indolence.

Two cases of thymomas with pure red cell aplasia (PRCA) are presented, highlighting variability in their anatomic location, ambiguity in presentation, indolence of course and unpredictability of response to treatment. Multi-modality approach is necessary for both diagnosis and management of this combination. Duration and side effects of treatment determine the overall prognosis.