Spectrum of malignant scalp tumours and its impact on management-a tertiary care cancer centre experience.

BACKGROUND: Tumours on the scalp are diverse and often exhibit site- and histology-specific characteristics. Reconstructing the scalp after oncological resection has always been challenging because of its unique anatomy. METHODOLOGY: A retrospective review of patients with malignant scalp tumour operated on at a single institution over 10 years was performed. Data were collected and analysed regarding the scalp tumour profile, treatment, and the outcome of these procedures. RESULTS: Of the 66 patients in our study, 33 (50%) had SCC. In addition to this, 21% were sarcomas, 17% were appendageal carcinomas, 11% were BCCs, and 1% was neuroendocrine carcinoma. Cortical erosion was observed in 6 patients in the CT imaging, all with SCC histology. Among the eight patients with pathological nodal involvement, three had angiosarcoma, three had SCC, one had appendageal carcinoma, and one had neuroendocrine carcinoma. The mean surgical defect size was 67.4 cm2. The surgical defect was reconstructed with local flaps in 58% of patients and primary closure in 27%. Local and systemic recurrence was noted in 25% of patients. Tumour size more than 6 cm, tumour histology (SCC & sarcoma), unplanned margin-positive excision, and residual disease in re-excision had higher recurrence, even though the p-value was not significant. CONCLUSION: Scalp tumours are heterogeneous in their clinical profiles. Often, its tumour biology and microscopic extent are underestimated. High suspicion, histological diagnosis, and clear surgical margins are all requirements in successfully treating scalp tumours. In order to minimize morbidity and restore an aesthetic and functional outcome, it is critical to use the simplest scalp reconstruction whenever possible.

Is it time to move away from polymyxins?: evidence and alternatives.

Increasing burden of carbapenem resistance and resultant difficult-to-treat infections are of particular concern due to the lack of effective and safe treatment options. More recently, several new agents with activity against certain multidrug-resistant (MDR) and extensive drug-resistant (XDR) Gram-negative pathogens have been approved for clinical use. These include ceftazidime-avibactam, meropenem-vaborbactam, imipenem-cilastatin-relebactam, plazomicin, and cefiderocol. For the management of MBL infections, clinically used triple combination comprising ceftazidime-avibactam and aztreonam is hindered due to non-availability of antimicrobial susceptibility testing methods and lack of information on potential drug-drug interaction leading to PK changes impacting its safety and efficacy. Moreover, in several countries including Indian subcontinent and developing countries, these new agents are yet to be made available. Under these circumstances, polymyxins are the only last resort for the treatment of carbapenem-resistant infections. With the recent evidence of suboptimal PK/PD particularly in lung environment, limited efficacy and increased nephrotoxicity associated with polymyxin use, the Clinical and Laboratory Standards Institute (CLSI) has revised both colistin and polymyxin B breakpoints. Thus, polymyxins 'intermediate' breakpoint for Enterobacterales, P. aeruginosa, and Acinetobacter spp. are now set at ≤ 2 mg/L, implying limited clinical efficacy even for isolates with the MIC value 2 mg/L. This change has questioned the dependency on polymyxins in treating XDR infections. In this context, recently approved cefiderocol and phase 3 stage combination drug cefepime-zidebactam assume greater significance due to their potential to act as polymyxin-supplanting therapies.

Predictive factors for nodal recurrence in differentiated thyroid cancers.

INTRODUCTION: Differentiated thyroid carcinoma usually has a good prognosis. Primary treatment is surgery, followed by radioactive iodine ablation based on risk stratification. The incidence of local and distant recurrence is 30%. Recurrence can be managed surgically or with multiple cycles of radioactive iodine ablation. There are multiple risk factors for structural disease recurrence proposed by the American Thyroid Association. In this study, we attempted to study the risk factors of structural recurrence in differentiated carcinoma thyroid and the pattern of recurrence in patients with node negative thyroid cancer who underwent total thyroidectomy. METHODOLOGY: This study selected a retrospective cohort of 1498 patients with differentiated thyroid cancer: out of these, 137 patients who presented after thyroidectomy with cervical nodal recurrence from January 2017 to December 2020 were included. The risk factors for central and lateral lymph node metastasis were analysed by univariate and multivariate analyses, including age, gender, T-stage, extrathyroidal extension, multifocality and high-risk variants. In addition, the presence of TERT/BRAF mutations was studied as a risk factor for central and lateral nodal recurrence. RESULTS: Out of 1498 patients, 137 who fit the inclusion criteria were analysed. Majority were female (73%); mean age was 43.1 years. Lateral compartment neck nodal recurrence was more common (84%), while isolated central compartment nodal recurrence occurred only in 16%. Most recurrences were seen in the first 1 year (23.3%) or after 10 years post-total thyroidectomy (35.7%). On univariate variate analysis, multifocality, extrathyroidal extension and high-risk variants stage were significant factors for nodal recurrence. However, on multivariate analysis for lateral compartment recurrence, multifocality, extrathyroidal extension and age were found to be significant. On multivariate analysis, multifocality, extrathyroidal extension and presence of high-risk variants were significant predictors of central compartment nodal metastasis. ROC curve analysis showed AUC for ETE (AUC-0.795), multifocality (AUC-0.860), presence of high-risk variants (AUC-0.727) and T-stage (AUC-0.771) as sensitive predictive factors for central compartment. 69 percent patients with very early recurrences (<6 month) had TERT/BRAF V600 E mutations. CONCLUSION: In our study, we have noted extrathyroidal extension and multifocality as significant risk factors for nodal recurrence. BRAF and TERT mutations are associated with aggressive clinical course and early recurrences. There is limited role of prophylactic central compartment node dissection.

Impact of COVID-19 on Disease Progression and Postoperative Complications in Patients with Head and Neck Cancer.

The COVID-19 pandemic has created a remarkable challenge for the healthcare system. The delayed presentation, diagnosis, and treatment of head and neck cancer during the COVID-19 pandemic is expected to adversely affect outcomes. COVIDSurg collaborative group in 2020 concluded surgery ≥ 4 weeks after a positive COVID-19 swab result was associated with a lower risk of postoperative mortality. The aim of this study is to assess the disease progression due to COVID-19 infection in patients with head and neck cancer planned for surgery and to analyze the postoperative complications in head and neck cancer patients who underwent surgery after COVID-19 infection. This is an ambispective observational study and included patients with head and neck cancer who recovered from COVID-19 infection and underwent surgery from June 2020 to May 2022. There were a total of 1849 patients with head and neck cancer operated in the mentioned study period during COVID-19 pandemic. One hundred fifty-nine patients had documented COVID-19 infection. One hundred two patients had oral cavity carcinoma (64%), and 38 patients had thyroid carcinoma (23.8%). Early disease was noted in 49 patients (30.8%) and locally advanced disease in 108 patients (67.9%). Mean duration of delay in surgery was 4 weeks. Disease progression was noted in 27 patients (17%) out of which 15 patients were inoperable. Thirty-seven out of 159 patients (23%) had postoperative complications, and it included 2 mortality. There was increased trend noted in pulmonary complications and hemorrhage when compared to pre-COVID-19 era. Due to COVID-19 pandemic, delayed elective head and neck cancer surgery has resulted in higher rates of inoperability. COVID-19 has been associated with increased postoperative pulmonary complications and hemorrhage.

Abdominal Surgical Emergencies in Patients with Hematological Disorders: An Exacting Experience for Surgeons.

Management of surgical emergencies in patients with underlying hematological disorder is challenging due to increased incidence of peri-operative morbidity. We report two cases of abdominal surgical emergencies with pre-existing hematological conditions. The first case report is that of a patient diagnosed with pelvic abscess in a previously diagnosed case of Glanzmann's thrombasthenia and the second is a case of intestinal infarction previously diagnosed with paroxysmal nocturnal hemoglobinuria (PNH).