Impact of preoperative COVID infection on the outcomes of planned curative-intent cancer surgeries in the second wave of the pandemic from a tertiary care center in India.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic was an unforeseen calamity. Sudden disruption of nonemergency services led to disruption of treatment across all specialties. Oncology revolves around the tenet of timely detection and treatment. Disruption of any sort will jeopardize cure rates. The time interval between coronavirus infection and cancer surgery is variable and needs to be tailored to avoid the progression of the disease. METHODS: We analyzed the impact of preoperative coronavirus disease 2019 (COVID-19) infection on the planned cancer surgery, delay, disease progression, and change of intent of treatment from April 1 to May 31, 2021 at a tertiary care center. All preoperative positive patients were retested after 2 weeks and were considered for surgery if the repeat test was negative and asymptomatic. FINDINGS: Our study included 432 preoperative patients of which 91 (21%) were COVID-19 positive. Amongst this cohort, 76% were operated and the morbidity and mortality were comparable to the COVID-19 negative cohort. Around 10% of the COVID-19 positive were lost to follow up and 10% had disease progression and were deemed palliative INTERPRETATION: SARS-CoV-2 infection has adversely impacted cancer care and a 2-week waiting period postinfection seems to be a safe interval in asymptomatic individuals to consider radical cancer surgery.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey.

PURPOSE: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers. METHODS: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era. RESULTS: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase. CONCLUSION: Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

Continuing surgical care in cancer patients during the nationwide lockdown in the COVID-19 pandemic-Perioperative outcomes from a tertiary care cancer center in India.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has disrupted management of non-COVID-19 illnesses, including cancer. For many solid organ cancers, surgical intervention is imperative. We present our experience with major operations during a nationwide lockdown. METHOD: This was an observational study of 184 patients, analyzing their perioperative outcomes and categorizing morbidity according to Clavien-Dindo Classification. Strict screening required symptomatic patients to be referred to COVID centers and their operations postponed. Continuous and categorical variables were expressed as medians with range and frequencies and percentages, respectively. A two-sided α < .05 was statistically significant. RESULTS: During the lockdown, we initiated a graded response over four phases: (I) 24 March to 14 April (18 procedures); (II) 15 April to 3 May (26 procedures); (III) 4 to 17 May (41 procedures); and (IV) 18 to 31 May (99 procedures). The rates of major perioperative morbidity were 10.9% and mortality 1.6%. Over the four phases, the major morbidity rates were 11.1%, 15.4%, 9.8%, and 13.1%. On multivariate analysis, an emergency procedure was the only significant factor associated with morbidity. During the study period, no hospital staff became symptomatic for COVID-19. CONCLUSION: In a region with milder impact of COVID-19, treatment of cancer patients need not be deferred. Our study showed that with appropriate precautions, asymptomatic patients may undergo operations without increased morbidity to them and hospital staff.

Adjuvant radiotherapy versus observation following lumpectomy in ductal carcinoma in-situ: A meta-analysis of randomized controlled trials.

The role of adjuvant radiotherapy (RT) following lumpectomy for ductal carcinoma in-situ (DCIS) was addressed in four major randomized controlled trials (RCTs) which were conducted two to three decades ago. Initial results of these trials suggested the protective role of RT in reducing the ipsilateral breast recurrences. Long-term results of all these four trials, based on more than 10-years follow-up data, have recently been published. A meta-analysis of four published RCTs which have addressed the role of adjuvant RT following lumpectomy for DCIS was conducted. Review manager (Cochrane Collaboration's software) version RevMan 5.2 was used for analysis. Evaluated events were ipsilateral breast recurrences (both DCIS and invasive), regional recurrences, contralateral breast events, distant recurrences, and overall mortality. The events were entered as dichotomous variable. The present meta-analysis included four RCTs and a total of 3680 patients - 1710 received adjuvant RT following lumpectomy while 1970 patients did not receive any adjuvant treatment. Patients who received RT had almost half of risk of ipsilateral breast recurrence (RR = 0.53, 95% CI = 0.45-0.62) and regional recurrence (RR = 0.54, 95% CI = 0.32-0.91) compared to those who did not receive adjuvant treatment - there was absolute risk reduction in 15% (95% CI = 12%-17%) for ipsilateral breast recurrences in adjuvant RT treated patients. There was no significant difference in distant recurrence (RR = 1.06, 95% CI = 0.74-1.53), contralateral breast events (RR = 1.22, 95% CI = 0.98-1.52) and overall mortality (RR = 0.93, 95% CI = 0.79-1.09). Though addition of postoperative RT to lumpectomy does not reduce overall mortality, the present meta-analysis confirms that it decreases the ipsilateral breast and regional recurrence by almost half.

Adjuvant Gemcitabine Plus Cisplatin and Chemoradiation in Patients With Gallbladder Cancer: A Randomized Clinical Trial.

Importance: There is limited evidence with regard to the benefit of adjuvant chemotherapy chemoradiotherapy in resected gallbladder cancers (GBCs). Objective: To establish a baseline survival rate for operated GBCs in patients receiving either gemcitabine plus cisplatin (GC) or capecitabine and capecitabine concurrent with chemoradiation (CCRT). Design, Setting, and Participants: The GECCOR-GB study was a multicenter, open-label, randomized phase 2 noncomparator "pick the winner" design trial of adjuvant GC and CCRT in patients with resected histologically confirmed adenocarcinoma or adenosquamous carcinoma of the gallbladder, (stage II/III) with no local residual tumor (R0) or microscopic residual tumor (R1). The study was carried out in 3 tertiary cancer institutions in India. Patients 18 years or older with adequate end-organ functions, and Eastern Cooperative Oncology Group Performance Status of 1 or lower between May 2019 and February 2022 were enrolled. The cutoff date for data analysis was February 28, 2023. Interventions: Patients were randomized 1:1 to receive either GC every 3 weeks (maximum of 6 cycles) or CCRT comprising capecitabine with concurrent chemoradiation (capecitabine concurrent with radiotherapy) sandwiched between capecitabine chemotherapy. Main Outcomes and Measures: The primary outcome was disease-free survival (DFS) at 1 year in randomized patients. This study was conducted as 2 parallel, single-stage phase 2 clinical trials. Within each treatment arm, a 1-year DFS rate of less than 59% was considered as insufficient activity, whereas a 1-year DFS rate of 77% or higher would be considered as sufficient activity. Results: With a median follow-up of 23 months, 90 patients were randomized, 45 in each arm. Overall, there were 31 women (69%) and 14 men (31%) in the GC arm with a mean (range) age of 56 (33-72) years and 34 women (76%) and 11 men (24%) in the CCRT group with a mean (range) age of 55 (26-69) years. In the GC and CCRT arms, 1-year DFS and estimated 2-year DFS was 88.9% (95% CI, 79.5-98.3) and 74.8% (95% CI, 60.4-89.2), and 77.8% (95% CI, 65.4-90.2) and 74.8% (95% CI, 59.9-86.3), respectively. Completion rates for planned treatment was 82% in the GC arm and 62% in the CCRT arm. Conclusions and Relevance: In this randomized clinical trial, GC and CCRT crossed the prespecified trial end points of 1-year DFS in patients with resected stage II/III GBCs. The results set a baseline for a larger phase 3 trial evaluating both regimens in operated GBCs. Trial Registration: ClinicalTrials.gov Identifier: CTRI/2019/05/019323I.

Technical description of a regional lymphadenectomy in radical surgery for gallbladder cancer.

BACKGROUND: The guidelines for resection of gallbladder cancer include a regional lymphadenectomy; yet it is uncommonly performed in practice and inadequately described in the literature. The present study describes the technique of a regional lymphadenectomy for gallbladder cancer, as practiced by the author. METHODS/TECHNIQUE: After confirming resectability, the duodenum is kocherized. The dissection starts from the posterior aspects of the duodenum and head of the pancreas and extends superiorly to the retroportal area. This is followed by dissection of the common hepatic artery and its branches, the bile duct and the anterior aspect of the portal vein until the hepatic hilum. Resection of the gallbladder with an appropriate liver resection completes the surgery. RESULTS: This technique was used for a regional lymphadenectomy in 27 patients, of which 14 underwent radical cholecystectomy upfront, and 13 had revisional surgery for incidentally detected gallbladder cancer. The median number of lymph nodes dissected on histopathology was 8 (range 3 to 18). Eleven patients had metastatic lymph nodes on histopathological examination. There was no post-operative mortality. Two patients had a bile leak which resolved with conservative management. CONCLUSION: A systematic approach towards a regional lymphadenectomy ensures a consistent nodal harvest in patients undergoing radical resection for gallbladder cancer.

Managing leaks following anterior resections: a new classification system.

BACKGROUND/AIMS: Anastomotic leak rates following rectal resections and anastomosis stand at 2.9-15.3%, with an attendant mortality rate of 6- 39.3%. The aim of our study was to identify those patients who had developed an anastomotic leak, and evaluate the indications for re-exploration as well as study the impact of covering colostomies on the subsequent outcome. METHODOLOGY: We analyzed 266 consecutive anterior resections for rectal cancer performed at a single institution between 1st September 2002 and 31st December 2006. RESULTS: Twenty-one anastomotic leaks were encountered in 266 resections. Covering colostomies were performed in 56% (151/266) of the patients. Out of the 21 patients who developed a leak, 9 had a covering colostomy (42.8%). In this group, 3 of patients (33%) could be managed without surgical re-exploration, while all the 12 patients without a covering colostomy had to undergo a reexploration. With our new classification system for anastomotic dehiscence, the clinical decisions appear to follow a predictable pattern. There were 4 deaths (1.5%). However, the mortality rate in the patients undergoing surgical re-exploration for complications was 16.6% (3/18). CONCLUSIONS: This large study provides an insight into the potential advantages of covering colostomies wherever indicated following anterior resections. With our new and effective classification system for clinical leaks, the management road map can be simplified and standardized.

Uterine collision tumor of endometrial stromal sarcoma and endometrioid adenocarcinoma: A rare case report and review of literature.

Collision tumors are characterized by occurrence of two or more histologically distinct tumor types at the same anatomic site. Collision tumors have been reported in various organs, such as esophagus, stomach, colon, kidney, lung, skin, thyroid, breast, ovary and uterus. Uterine collision tumors of epithelial and mesenchymal origin are rare and often underrecognized. We report a rare concurrent occurrence of endometrial stromal sarcoma and endometrioid adenocarcinoma in a 65-year-old female. It is important to differentiate collision tumors from carcinosarcoma due to impact on clinical management and prognosis. Extensive gross sampling and careful morphological examination aided by immunohistochemical studies is necessary for the diagnosis of this rare entity. This case report aims to increase the awareness of this rare pathological entity with discussion on the management issue based on review of literature. This is the first case in Indian literature to the best of our knowledge.

Detection of human papillomavirus infection in oral cancers reported at dental facility: assessing the utility of FFPE tissues.

Incidence of human papillomavirus (HPV)-associated oral cancers is on the rise. However, epidemiological data of this subset of cancers are limited. Dental hospital poses a unique advantage in detection of HPV-positive oral malignancies. We assessed the utility of formalin-fixed paraffin-embedded (FFPE) tissues, which are readily available, for evaluation of high-risk HPV infection in oral cancer. For protocol standardization, we used 20 prospectively collected paired FFPE and fresh tissues of histopathologically confirmed oral cancer cases reported in Oral Medicine department of a dental hospital for comparative study. Only short PCRs (~ 200 bp) of DNA isolated using a modified xylene-free method displayed a concordant HPV result. For HPV analysis, we used additional 30 retrospectively collected FFPE tissues. DNA isolated from these specimens showed an overall 23.4% (11/47) HPV positivity with detection of HPV18. Comparison of HPV positivity from dental hospital FFPE specimens with overall HPV positivity of freshly collected oral cancer specimens (n = 55) from three cancer care hospitals of the same region showed notable difference (12.7%; 7/55). Further, cancer hospital specimens showed HPV16 positivity and displayed a characteristic difference in reported sub-sites and patient spectrum. Overall, using a xylene-free FFPE DNA isolation method clubbed with short amplicon PCR, we showed detection of HPV-positive oral cancer in dental hospitals.

Carcinoma buccal mucosa with left axillary lymph node metastasis: First reported case and review of the literature.

Head-and-neck squamous cell carcinomas are tumors with propensity mostly for locoregional spread. The most frequent sites of metastasis include lung, bone, liver, adrenal, heart, and kidney. Distant metastasis to axillary lymph nodes from buccal mucosa cancer is extremely rare. To the authors' knowledge, this is the first case reported where a gentleman who was treated for carcinoma right buccal mucosa developed left axillary lymph node metastasis at 6th year of follow-up.

Sequential EGFR mutation and ALK rearrangement in adenocarcinoma lung, with rare metastasis to bilateral breast, ovary and endometrium.

With the advent of targeted therapies there was a paradigm shift in the treatment of metastatic adenocarcinoma of lung. Immuno-histopathology and molecular subtyping in metastatic adenocarcinoma lung have enabled personalized treatment for each patient. Oncogenic driver mutations in non-small cell lung cancer are commonly EGFR (Epidermal Growth Factor Receptor) gene mutation and ALK (Anaplastic Lymphoma Kinase) gene rearrangement, which are mutually exclusive. Almost 60-64% patients have oncogenic mutation, which are mutually exclusive. Here, we present a case with EGFR mutation and ALK gene rearrangement which was expressed sequentially and with metastasis to rarest sites bilateral breast, ovaries and endometrium. Even though presented with upfront metastatic disease, patient was treated with multiple lines of targeted agents, by which patient survived for 5 years with good quality of life.

Isolated hepatosplenic tuberculosis.

BACKGROUND: Tuberculosis rarely involves the liver and spleen and when it does so, it is usually associated with disseminated disease. METHOD: We report a patient with isolated tuberculosis of the liver and spleen. RESULTS: A 50-year-old man presented with weakness and loss of weight for two months. CT scan of the abdomen showed multiple small hypodense lesions in the liver and spleen. Image-guided biopsy of liver lesion was inconclusive as it showed normal hepatocytes with interspersed lymphocytes. On laparotomy, the liver and spleen were studded with multiple small nodules. A 5-cm wedge of the liver was resected. Histopathological examination confirmed the diagnosis of tubercular hepatitis. A detailed work-up failed to identify any other focus of tuberculosis. CONCLUSION: Although rare, tuberculosis should also be considered in the differential diagnosis for multiple nodules in the liver and spleen, along with lymphoproliferative diseases and metastatic lesions.

Surgical resection of adrenal metastasis from primary liver tumors: a report of two cases.

BACKGROUND: Although the treatment of extrahepatic metastases from primary liver tumors is essentially palliative, solitary metastasis from such tumors offers a possibility of cure by surgical resection. The adrenal gland is an uncommon site for metastasis from primary liver tumors. METHOD: We report two cases of adrenalectomy for solitary adrenal metastasis: one from intrahepatic cholangiocarcinoma and the other from hepatocellular carcinoma. RESULTS: The patient with intrahepatic cholangiocarcinoma had a synchronous adrenal metastasis and underwent simultaneous liver resection and adrenalectomy. However, he developed recurrent disease 17 months following surgery for which he is presently on palliative chemotherapy. The other patient underwent adrenalectomy for adrenal metastasis 3 months following liver transplantation for hepatocellular carcinoma. He is presently alive and disease-free 27 months after adrenalectomy. CONCLUSION: Carefully selected patients with solitary metastasis from primary liver tumors may be considered for resection.