Sarcopenia in gastric cancer and its impact on early postoperative outcome.

BACKGROUND: Sarcopenia, defined as progressive and generalised loss of skeletal muscle mass, quality, and strength, is considered as a poor prognostic factor in cancer. Outcomes in oncology mainly focus on survival related to disease and treatment. Other factors affecting the end result get less attention. This study was conducted with the aim to determine presence of sarcopenia in operable gastric cancer, factors positively correlating with presence of sarcopenia and its impact on early postoperative outcomes. METHODOLOGY: This is a prospective study conducted from January 2020 to December 2021 in a tertiary care cancer hospital. All patients with adenocarcinoma stomach planned for curative intent surgery were assessed for sarcopenia by measuring hand grip strength(HGS) and skeletal muscle index(SMI). Comparison was made between patient and tumour related factors in patients with and without sarcopenia and impact of sarcopenia on early postoperative outcome was assessed. RESULTS: 74 patients were assessed for sarcopenia. 32 (43.2 %) were patients diagnosed with sarcopenia. Advanced age(p = 0.040), low BMI (p < 0.001), gastric outlet obstruction (p = 0.020) and urgent surgery (p = 0.002) positively correlated with sarcopenia. Curative resection was done in 68(91.89 %) patients and these patients were evaluated for early postoperative outcomes. 18 (26.5 %) patients had complications of Clavien Dindo grade 3 or above. Sarcopenia was not significantly associated with major postoperative complications(p = 0.857). CONCLUSION: Sarcopenia, though associated with a substantial proportion of patients with gastric cancer, does not significantly affect early postoperative complications in a high volume oncology centre .

Low Anterior Resection Syndrome and Quality of Life of Patients After Sphincter Preservation Surgery: A Prospective Study.

Background After anterior resection (AR), one of the most debilitating complications is low anterior resection syndrome (LARS) seen in about 64% of patients. The severity of the LARS score was significantly correlated with neoadjuvant treatment, the extent of rectal surgery, complication by the anastomotic leak, female gender, and age < 64 years. In this study, we analyzed the impact of various clinical factors on LARS and also the various domains of quality of life (QoL). Purpose To assess the incidence of LARS in patients undergoing sphincter-sparing surgery for rectal cancer after the patient starts long-term defecating per anus, change in the QoL, and relation to LARS and factors affecting it. Methods One year before, 72 patients who had undergone AR in the Regional Cancer Centre were interviewed by a trained interviewer and data was collected from the file. The questionnaires used were the Wexner Incontinence score, LARS Malayalam Questionnaire, and European Organisation For Research and Treatment of Cancer (EORTC) QLQ C30 Malayalam translations. Statistical measures The LARS score was used to categorize patients into three grades. The scores were compared with clinical and social factors using the χ2 test for association. Continuous variables were compared by the Spearman Rho test. Results Details of patients were studied (male: 55.6% (40) and female: 44.4% (32)). Fifty patients underwent low anterior resection (LAR). The mean LARS score was 25.61, with 47.2% of patients having severe LARS score. The mean Wexner score was 6.84. The relation with type of surgery, approach (laparoscopic vs open), or type of neoadjuvant therapy was not found to be significant. A higher LARS score did not impact overall QoL as assessed by FACT-C. Insomnia and diarrhea symptoms scores were significantly worsened. The pain score was worse for those undergoing stapler anastomosis. Wexner's score was worse for those who had received adjuvant chemotherapy. Role functioning score was better for AR compared to low anterior resection (LAR). Only distance from the anal verge was found to be a significant cause of LARS and was negatively correlated. Discussion LARS of severe degrees were seen in most patients. No modifiable risk factors were significantly found to affect the chance of LARS. However, LARS did not have a significant impact on QoL, neither did the type of surgery. So sphincter preservation can be offered to the patients, but all patients undergoing LAR should be counseled well about the risk of LARS before surgery.

Sacral Resections for Primary Sacral Tumor - an Experience from a Tertiary Care Cancer Center in India.

Primary sacral tumors are uncommon and sacrectomy is a complex surgical procedure with substantial risk of morbidity. We conducted a retrospective study of patients who had undergone sacral resections for primary sacral tumors between 2010 and 2020. Ten sacral resections including five type 1 sacrectomy (S1 resected), four type 2 (S1 spared), and one type 3 (S3 spared) were performed during the above period. The median age was 47 years and the most common histologic diagnosis was chordoma (50%). The median operating time was 705 min (range 180-960 min) with a median blood loss of 3400 ml (range 500-7000 ml) and a median duration of hospital stay of 13.5 days (range 7-68 days). All patients who underwent type 1 sacrectomy experienced major complications (Clavien-Dindo grade 3 or above) including one death in the immediate perioperative period. Microscopically positive margins (R1) were noted in two patients (20%). All patients with type 1 sacrectomy had R0 resection. The median follow-up period was 31 months. The median MSTS score was 12 (range 4-27). A total of seven patients (70%) had a minimum follow-up of 2 years without disease recurrence. Sacral resection for primary tumors of the sacrum with oncologically safe margins is feasible. Although associated with substantial perioperative morbidity, a detailed preoperative planning and execution of the surgery by a team of orthopedic oncosurgeon, surgical oncologist, and plastic surgeon offer a hope for survival in patients with acceptable functional outcome.

Prognostic Implications of Various Surgical Procedures and Postoperative Margin Status in Gastroesophageal Junction Tumors.

Esophagogastric junction (EGJ) carcinomas often require access to two compartments of the body for good margin and lymphadenectomy. Whether it is required to do so in all patients is debatable. We analyzed outcomes of patients who underwent surgeries for EGJ carcinomas in terms of margin status and survival. This is a retrospective analysis of a prospectively maintained database of patients with EGJ adenocarcinomas operated between January 2014 and December 2016. Type of surgery performed and its impact on margin status and survival were assessed. Follow-up was for a minimum of 5 years. Ninety-four patients with EGJ carcinomas were operated on during the study period. Eight (8.51%) had involved proximal margin, and 2 of these had positive distal margin also. None had distal margin alone involved. Seventeen (18.09%) and 5 (5.32%) had a close proximal and distal margin, respectively. Radial margin was close/involved in 6 (6.38%) patients. Five-year overall survival and disease-free survival for the cohort was 38% and 30.8%, respectively. Proximal gastrectomy had a higher proximal margin positivity. Positive proximal or distal margin and a close/involved radial margin were detrimental to disease free survival and overall survival. Proximal gastrectomy is associated with a higher likelihood of proximal margin positivity. Positive margin leads to lower survival. Whether involvement of margins is just a surrogate marker of aggressive tumor or is an error in assessing extent tumor needs to be studied. Large-scale prospective studies in this regard are desirable.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer.

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

Validation of Malayalam Translation of the European Organization for the Research and Treatment of Cancer Quality of Life Instrument OG25 for Esophagogastric Junction Cancers.

BACKGROUND: Quality of life questionnaire (QLQ) OG25 is the questionnaire used for measuring quality of life (QOL) of patients with esophago-gastric junction (OG) cancers. QLQ-OG 25 is a disease-specific tool to capture the QOL parameters of patients with OG junction cancers. OG 25 was developed by the European Organization for the Research and Treatment of Cancer (EORTC) using inspiration from their questionnaires for carcinoma stomach (STO22) and carcinoma esophagus (OES18). It is usually used along with QLQ-C30, which is a general tool applicable for all cancers. This questionnaire is in the English language. In order to use this questionnaire in a non-English speaking population, the English questionnaire has to be initially translated to the local languages. Malayalam is the language spoken by 38.5 million people residing in the South Indian state, Kerala, India. We have translated and validated the QLQ-OG 25 to Malayalam language in an attempt of enabling it to be used for future studies at this geographic region. METHODS: The translation was done by the standard protocol adopted by EORTC. QLQ-C30 and QLQ-OG25 questionnaires were then filled in by patients with OG junction cancers. These patients had cancers of various subsites of the OG junction and were at different stages of treatment, at the time of interview. The interview was done twice, at an interval ranging from 48 h to 1 week between the two interviews. RESULTS: A total of 46 patients with OG junction tumors at varying stages of treatment completed the questionnaire. There were no missing data. The average time to finish the interview was 12.12 min. The Cronbach's alpha, which signifies the internal consistency of the questionnaire, was found to be >0.7 in all the domains studied, except in cognitive function. The intraclass correlation coefficients varied from 0.63 to 0.93. CONCLUSION: The Malayalam translation of the QOL tool QLQ-OG25 has been found to be an acceptable and valid tool in assessing the QOL parameters of patients with OG junction cancers.

Hot liver on 18F-FDG PET/CT imaging-a quandary for oncoradiologists in South Asia.

A 56-year-old female presented with intermittent hemoptysis and was diagnosed with lung cancer. 18F-fluorodeoxyglucose positron emission tomography/CT for staging revealed hypermetabolic liver (hot liver), uptake in the mediastinal lymph nodes and reduced uptake in the kidneys. Unexpectedly, liver biopsy findings were consistent with tuberculous infection. Following the intensive phase of antituberculous treatment, repeat CT revealed significant resolution of the mediastinal lymph nodes making the lung cancer Stage 1 (T1 lesion). She underwent left lower lobectomy as a definitive surgical treatment. Positron emissiontomography/CT scan in this patient was considered to be a hepatic superscan since it revealed a hot liver.

The City of Hope Quality of Life Stoma Questionnaire: Malayalam Translation and Validation.

BACKGROUND: Malayalam is the language spoken by 38.5 million people worldwide. There is no specific instrument to measure stoma-related quality of life (QOL) in Malayalam language. AIM: This study was designed to translate and validate the city of hope QOL (COH-QOL) Ostomy Questionnaire, which is a robust tool developed in English language. MATERIALS AND METHODS: The instrument was translated to Malayalam, abiding by internationally accepted translation methodology. Trained interviewer (first author) administered the questionnaire to patients with stoma, who were visiting the stoma clinic. The reliability of the subscales and the total scores were established by calculating correlation coefficients. Convergent and divergent validity were evaluated by calculating Pearson's correlations of each item with its own scale and other scales. RESULTS: Cronbach's alpha coefficients for all subscales were 0.70 or more. Similarly, split-half coefficients also were more than 0.70, which were acceptable. All subscales met the minimum acceptable standards of convergent and discriminant validity. Discriminant validity of all scores was less than convergent validity which suggests that there was no overlap between various constructs in measuring the same traits. The validation study of Malayalam translation of COH stoma questionnaire has shown that the tool is valid and reliable. CONCLUSION: The validation study of Malayalam translation of City of Hope Stoma questionnaire has shown the tool is valid and reliable.

Nipple Areola Complex Involvement in Invasive Carcinoma Breast.

A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.

Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre.

The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.

Triple Test-a Predictor of Anastomotic Integrity in Patients Undergoing Low Anterior Resection After Neoadjuvant Chemoradiotherapy.

Anastomotic leak after low anterior resection for rectal cancer is a dreaded complication. Diversion stoma helps tiding over this crisis and it is routinely practised in most centres, especially in post chemoradiotherapy setting. But a diversion stoma has got its own problems. In this study, we attempt to use the triple test as a predictor of anastomotic integrity and thereby avoid a diverting stoma, and patients undergoing low anterior resection after neoadjuvant chemoradiotherapy were spared the trouble of a diverting stoma if the on table triple test was negative. Two hundred such consecutive patients were prospectively followed up in the postoperative period. The incidence of anastomotic leak and the factors predicting the same were analysed in this group of patients. The incidence of anastomotic leak in our study was 7%, which is much less when compared to published literature. The triple test was a reliable predictor of the integrity of anastomosis and if the test is negative, a diverting stoma can be avoided. Age more than 60 years and end-to-end anastomosis were found to be associated with increased incidence of leak, and patients with a negative triple test need not routinely undergo diversion stoma after a low anterior resection even in post chemoradiotherapy setting.

Oncological Safety of Breast Conservation Surgery in Young Females.

Breast conservation surgery (BCS) is the standard of care in early breast cancer. The oncological safety of this procedure has been proven beyond doubt in several randomised control trials. But there are concerns regarding the safety of this procedure in young females. The concern is regarding increased risk of local recurrence. This issue has not been addressed in any major trial. In this prospective study we intend to look into the oncological safety of BCS in young patients who are less than forty years of age.

Solid-pseudopapillary neoplasm of the pancreas: A classical presentation with unique paranuclear dot like immunostaining with CD 99.

A 32-year-old lady presented with a history of abdominal pain and upper abdominal discomfort of 3 months duration. Her imaging studies done at a local hospital showed a solid-cystic mass involving head of the pancreas. The patient was referred to our surgical oncology department. On examination, there was a nontender mass in the epigastrium. An ultrasound scan guided fine-needle aspiration (FNA) was done which was showing classical features of solid-pseudo papillary neoplasm of the pancreas. With this preoperative diagnosis patient was taken up for surgery. Per operatively, there was a solid-cystic mass in the head of the pancreas. Pancreaticoduodenectomy was done. Histopathology and immunohistochemistry (IHC) confirmed the diagnosis of solid-pseudo papillary neoplasm of the pancreas. Apart from the routine IHC panel, CD 99 immunostain was also done which demonstrated the characteristic paranuclear dot-like staining observed in previous studies in the literature.

Secretory carcinoma of breast in a patient treated for differentiated thyroid carcinoma-a diagnostic dilemma.

Secretory carcinoma of the breast is a rare entity accounting for less than 1 % of all infiltrating breast carcinomas. Though initially considered as "juvenile breast carcinoma", due to its occurrence predominantly in pediatric population, it was later found to present in other age groups as well. We report a case of secretory carcinoma breast in a middle aged woman who had undergone treatment for papillary carcinoma of thyroid previously. The uniqueness of this malignancy and the diagnostic dilemma due to patient's past medical history, are discussed in detail.

Pleomorphic adenoma of breast-a case report and review of literature.

Pleomorphic adenoma (PA) is a rare benign tumour of the breast. However inadequate surgery of this tumour, which is notorious for its pseudopod like extension into adjacent tissue, results in recurrence. We report a case of pleomorphic adenoma of the breast that has been excised at a local hospital and then referred to a tertiary care hospital for definite management. The diagnostic dilemmas and optimal management, of such cases where dependable pathology report and details of primary surgery are often not available, are discussed.

Squamous cell carcinoma arising from long-standing perianal fistula.

Perianal fistula is a very common problem in general population. Ninety percent of perianal fistulae arise from infected anal glands, and they often give rise to perianal abscesses. Very rarely perianal fistulae and abscesses undergo malignant transformation and give rise to carcinomas, mainly adenocarcinomas. We are reporting a case of squamous cell carcinoma arising from long-standing perianal fistula and how we managed it surgically.