Effect of Peritumoral Infiltration of Local Anesthetic Before Surgery on Survival in Early Breast Cancer.

PURPOSE: Preventing metastases by using perioperative interventions has not been adequately explored. Local anesthesia blocks voltage-gated sodium channels and thereby prevents activation of prometastatic pathways. We conducted an open-label, multicenter randomized trial to test the impact of presurgical, peritumoral infiltration of local anesthesia on disease-free survival (DFS). METHODS: Women with early breast cancer planned for upfront surgery without prior neoadjuvant treatment were randomly assigned to receive peritumoral injection of 0.5% lidocaine, 7-10 minutes before surgery (local anesthetics [LA] arm) or surgery without lidocaine (no LA arm). Random assignment was stratified by menopausal status, tumor size, and center. Participants received standard postoperative adjuvant treatment. Primary and secondary end points were DFS and overall survival (OS), respectively. RESULTS: Excluding eligibility violations, 1,583 of 1,600 randomly assigned patients were included in this analysis (LA, 796; no LA, 804). At a median follow-up of 68 months, there were 255 DFS events (LA, 109; no LA, 146) and 189 deaths (LA, 79; no LA, 110). In LA and no LA arms, 5-year DFS rates were 86.6% and 82.6% (hazard ratio [HR], 0.74; 95% CI, 0.58 to 0.95; P = .017) and 5-year OS rates were 90.1% and 86.4%, respectively (HR, 0.71; 95% CI, 0.53 to 0.94; P = .019). The impact of LA was similar in subgroups defined by menopausal status, tumor size, nodal metastases, and hormone receptor and human epidermal growth factor receptor 2 status. Using competing risk analyses, in LA and no LA arms, 5-year cumulative incidence rates of locoregional recurrence were 3.4% and 4.5% (HR, 0.68; 95% CI, 0.41 to 1.11), and distant recurrence rates were 8.5% and 11.6%, respectively (HR, 0.73; 95% CI, 0.53 to 0.99). There were no adverse events because of lidocaine injection. CONCLUSION: Peritumoral injection of lidocaine before breast cancer surgery significantly increases DFS and OS. Altering events at the time of surgery can prevent metastases in early breast cancer (CTRI/2014/11/005228).[Media: see text].

A study of outcomes, technical safety, and feasibility of D-2 lymphadenectomy in gastric cancer.

BACKGROUND AND AIM: Lymph node dissection in gastric cancer had been controversial, but recent data have led us to the conclusion that D-2 dissection should be the standard of care for potentially curable advanced gastric carcinoma. In this study, we present our single-institution experience of D-2 lymph node dissection. METHODS: From January 2013 to September 2018, 115 patients of gastric cancer were treated with D-2 gastrectomy, 91 of whom met the criteria for study analysis. Data were statistically described as frequencies and percentages where appropriate. Survival curves were plotted using the Kaplan-Meier method, and Cox regression was used to assess the risk among groups. A P value <0.05 was considered to be statistically significant at 95% confidence interval. RESULTS: The majority of patients (86.8%) had Clavien-Dindo grade I postoperative surgical complications; 90-day mortality was seen in five (5.5%) patients. Patients with stages I, II, and III had survival rates of 100%, 71.4%; 53.2%, 44.4%; and 27.8%, 28.1%, respectively, for ages <55 and >55 years. Overall recurrence free survival rates were 26 and 28% for <55 years and >55 years, respectively, with a P value of 0.570. On multivariate analysis, positive distal margin and multivisceral resection had a statistically significant hazard ratio. CONCLUSIONS: This retrospective study conducted in our institute on patients with gastric cancer undergoing D-2 lymphadenectomy has shown that the addition of D-2 lymph node dissection, when performed at high-volume centers, have acceptable morbidity and mortality rates. This can be seen from our grades of postoperative surgical complications, 90-day mortality, and overall 5-year survival.

Nasojejunal Feeding Is Safe and Effective Alternative to Feeding Jejunostomy for Postoperative Enteral Nutrition in Gastric Cancer Patients.

Background and Aim Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them. Materials and Methods It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively. Results A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor. Conclusion Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.

A Study of Clinical Presentation and Management of Malignant Gastric Outlet Obstruction (Northeast India-Based Single-Centre Experience).

Gastric outlet obstruction (GOO) occurs when there is mechanical obstruction impending gastric emptying. GOO has both benign and malignant aetiologies. In this paper we want to discuss, clinical presentation and management of malignant GOO. This is a retrospective observational study of 5 years in patients presenting with malignant GOO. Study was conducted in Dr. B. Borooah Cancer Institute, Guwahati, India. Patients with malignant GOO who were operated were included in this study. Chi-square test was used to evaluate association between categorical values. Independent t test and one-way ANOVA (analysis of variance) was used for continuous variables. A p value < 0.05 was considered statistically significant at 95% confidence interval. Data were analysed using SPSS (Statistical Package for the Social Sciences) software. A total of 107 patients were included in the study. Mean age of patients was 51 years. Carcinoma stomach was the most common cause of GOO, followed by carcinoma gall bladder, pancreatic cancer and duodenal cancer in decreasing order of frequency. Gastrojejunostomy was done in 96 patients, and palliative gastrectomy with gastrojejunostomy was done in 11 patients. There was improvement in gastric outlet obstruction score in most of the patients after GJ with acceptable patency rates at the end of 90 days. Low albumin levels and poor preoperative performance status were associated with increased 90-day mortality. Patients with malignant GOO usually present in poor general condition. Carcinoma stomach was the major cause of GOO in our setup. Adequate preoperative resuscitation, nutritional assessment and correction of malnourishment are of utmost importance for improving outcome of patients. Surgical gastroenterostomy was effective for palliation of obstructive symptoms in our study with improvement in post-operative oral intake and improved quality of life. Our study of 107 patients with GOO has shown that surgical palliation of GOO in the form of gastrojejunostomy improves oral intake of patients with improved post-operative gastric-outlet obstruction scores. Low albumin levels and poor preoperative poor performance status were associated with increased mortality at the end of 90 days.

Status of epigenetic chromatin modification enzymes and esophageal squamous cell carcinoma risk in northeast Indian population.

Esophageal cancer incidence is reported in high frequency in northeast India. The etiology is different from other population at India due to wide variations in dietary habits or nutritional factors, tobacco/betel quid chewing and alcohol habits. Since DNA methylation, histone modification and miRNA-mediated epigenetic processes alter the gene expression, the involvement of these processes might be useful to find out epigenetic markers of esophageal cancer risk in northeast Indian population. The present investigation was aimed to carryout differential expression profiling of chromatin modification enzymes in tumor and normal tissue collected from esophageal squamous cell carcinoma (ESCC) patients. Differential mRNA expression profiling and their validation was done by quantitative real time PCR and tissue microarray respectively. Univariate and multiple logistic regression analysis were used to analyze the epidemiological data. mRNA expression data was analyzed by Student t-test. Fisher exact test was used for tissue microarray data analysis. Higher expression of enzymes regulating methylation (DOT1L and PRMT1) and acetylation (KAT7, KAT8, KAT2A and KAT6A) of histone was found associated with ESCC risk. Tissue microarray done in independent cohort of 75 patients revealed higher nuclear protein expression of KAT8 and PRMT1 in tumor similar to mRNA expression. Expression status of PRMT1 and KAT8 was found declined as we move from low grade to high grade tumor. Betel nut chewing, alcohol drinking and dried fish intake were significantly associated with increased risk of esophageal cancer among the study subject. Study suggests the association of PRMT1 and KAT8 with esophageal cancer risk and its involvement in the transition process of low to high grade tumor formation. The study exposes the differential status of chromatin modification enzymes between tumor and normal tissue and points out that relaxed state of chromatin facilitates more transcriptionally active genome in esophageal carcinogenesis.

The growing burden of cancer in India: epidemiology and social context.

Cancer can have profound social and economic consequences for people in India, often leading to family impoverishment and societal inequity. Reported age-adjusted incidence rates for cancer are still quite low in the demographically young country. Slightly more than 1 million new cases of cancer are diagnosed every year in a population of 1.2 billion. In age-adjusted terms this represents a combined male and female incidence of about a quarter of that recorded in western Europe. However, an estimated 600,000-700,000 deaths in India were caused by cancer in 2012. In age-standardised terms this figure is close to the mortality burden seen in high-income countries. Such figures are partly indicative of low rates of early-stage detection and poor treatment outcomes. Many cancer cases in India are associated with tobacco use, infections, and other avoidable causes. Social factors, especially inequalities, are major determinants of India's cancer burden, with poorer people more likely to die from cancer before the age of 70 years than those who are more affluent. In this first of three papers, we examine the complex epidemiology of cancer, the future burden, and the dominant sociopolitical themes relating to cancer in India.

Delivery of affordable and equitable cancer care in India.

The delivery of affordable and equitable cancer care is one of India's greatest public health challenges. Public expenditure on cancer in India remains below US$10 per person (compared with more than US$100 per person in high-income countries), and overall public expenditure on health care is still only slightly above 1% of gross domestic product. Out-of-pocket payments, which account for more than three-quarters of cancer expenditures in India, are one of the greatest threats to patients and families, and a cancer diagnosis is increasingly responsible for catastrophic expenditures that negatively affect not only the patient but also the welfare and education of several generations of their family. We explore the complex nature of cancer care systems across India, from state to government levels, and address the crucial issues of infrastructure, manpower shortages, and the pressing need to develop cross-state solutions to prevention and early detection of cancer, in addition to governance of the largely unregulated private sector and the cost of new technologies and drugs. We discuss the role of public insurance schemes, the need to develop new political mandates and authority to set priorities, the necessity to greatly improve the quality of care, and the drive to understand and deliver cost-effective cancer care programmes.