Outcomes of Cancer Surgery During the COVID-19 Pandemic: Preparedness to Practising Continuous Cancer Care.

The COVID-19 pandemic has placed unprecedented pressure on healthcare services. Deprioritisation of nonemergency clinical services and growing concerns of adverse outcomes of COVID-19 in cancer patients is having a deleterious impact across oncologic practice. We report cancer surgery outcomes taking into account the acuity of the COVID-19 situation. A prospectively maintained database of the Department of Surgical Oncology was analysed from 1st May to 30th June, 2020, to evaluate the perioperative outcomes, morbidity and mortality following major surgical procedures. A total of 359, preoperatively, tested negative for COVID-19 underwent surgery. Median age was 52 years with 26.7% (n = 96) above the age of 60 years. Sixty-one percent (n = 219) patients were American Society of Anaesthesiology grades II-III. As per surgical complexity grading, 36.8% (n = 132) cases were lower grades (I-III) and 63.2% (n = 227) were complex surgeries (IV-VI). 5.3% (n = 19) had ≥ grade III Clavien-Dindo complication, and the postoperative mortality rate was 0.27% (n = 1). Major complication rates in patients > 60 years were 9.3% in comparison to 4.1% in < 60 years (p = 0·63). The median hospital stay was 1-10 days across subspecialties. Postoperatively, repeat COVID 19 testing in 2 suspected patients were negative. Our study showed that after screening, triaging and prioritisation, asymptomatic cases may undergo cancer surgeries without increased morbidity during COVID-19 pandemic.

Salvage Surgery in Recurrent Oral Squamous Cell Carcinoma.

More than half of patients with oral cancer recur even after multimodality treatment and recurrent oral cancers carry a poorer prognosis when compared to other sites of head and neck. The best survival outcome in a recurrent setting is achieved by salvage surgery; however, objective criteria to select an ideal candidate for salvage surgery is difficult to frame, as the outcome depends on various treatment-, tumor-, and patient-related factors. The following is summarizes various tumor- and treatment-related factors that guide our decision-making to optimize oncologic and functional outcomes in surgical salvage for recurrent oral cancers. Short disease-free interval, advanced tumor stage (recurrent and primary), extracapsular spread and positive tumor margins in a recurrent tumor, regional recurrence, and multimodality treatment of primary tumor all portend worse outcomes after surgical salvage. Quality of life after surgical intervention has shown improvement over 1 year with a drastic drop in pain scores. Various trials are underway evaluating the combination of immunotherapy and surgical salvage in recurrent head and neck tumors, including oral cavity, which may widen our indications for salvage surgery with improved survival and preserved organ function.

Genome-wide scan demonstrates significant linkage for male sexual orientation.

BACKGROUND: Findings from family and twin studies support a genetic contribution to the development of sexual orientation in men. However, previous studies have yielded conflicting evidence for linkage to chromosome Xq28. METHOD: We conducted a genome-wide linkage scan on 409 independent pairs of homosexual brothers (908 analyzed individuals in 384 families), by far the largest study of its kind to date. RESULTS: We identified two regions of linkage: the pericentromeric region on chromosome 8 (maximum two-point LOD = 4.08, maximum multipoint LOD = 2.59), which overlaps with the second strongest region from a previous separate linkage scan of 155 brother pairs; and Xq28 (maximum two-point LOD = 2.99, maximum multipoint LOD = 2.76), which was also implicated in prior research. CONCLUSIONS: Results, especially in the context of past studies, support the existence of genes on pericentromeric chromosome 8 and chromosome Xq28 influencing development of male sexual orientation.

Primary synchronous bilateral breast cancer.

Background: Primary synchronous bilateral breast cancer (PSBBC) is a rare clinical entity. The reported incidence ranges between 0.3% and 12%. There are several controversial issues regarding PSBBC pertaining to the diagnostic criteria, nomenclature, and management policies. Materials and Methods: Fourteen cases of PSBBC treated between 2001 to 2010 at our institute were retrospectively analysed in regards to demographic data, management and follow up. Results: PSBBC constituted 0.19% of total breast cancer patients at our institute. Age ranged from 28 to 78 years. PSBBC were detected by clinical examination in eight cases and by mammography in six cases. Twelve patients underwent bilateral modified radical mastectomy, one had unilateral mastectomy on one side and breast conservation on the other side and one patient has bilateral breast conservation. Majority of patients belonged to stage 2 and stage 3. All patients were found to have invasive ductal carcinoma. Five cases were ER/PR positive and 8 patients were triple hormone receptor negative. Eight patients received unilateral and six received bilateral adjuvant radiotherapy. Nine patients received adjuvant chemotherapy. 5 patients received adjuvant hormonal therapy. Median follow up of patients was 15.4 months. Conclusion: PSBBC is a rare event warranting awareness and screening of the contralateral breast in patients with unilateral breast cancer. These patients require individualized treatment planning based on the tumor factors of the index lesion. Further multi institutional prospective studies are needed for adequate understanding of management of PSBBC.

Predictive factors for loco regional recurrence and distant metastasis following primary surgical treatment of cutaneous melanoma.

BACKGROUND: Cutaneous melanoma (CM) has a high propensity for regional and systemic spread. This is one of the largest series of CM reported from India. AIMS: To predict factors for loco regional recurrence (LRR) and distant metastasis in patients with CM primarily treated with surgery. STUDY DESIGN: Retrospective analysis of patient database at a tertiary care cancer center with evaluation of factors for LRR and distant metastasis for CM. MATERIALS AND METHODS: Data from 68 patients treated for CM between January 2006 and December 2010 were reviewed. Data recorded included age, sex, symptoms, investigations, treatment given, histopathology, recurrence and follow-up. Patient factors, tumor factors, pathologic variables, and adjuvant treatment were investigated as predictors' of LRR and distant metastasis. RESULTS: Mean age of patients was 54 years. Melanoma was more common in males (44). Tumor thickness > 4 mm was found in 43 patients. Lymph node involvement was found in 43 patients. Adjuvant radiotherapy was given in seven patients. At mean follow-up of 16.5 months, LRR was seen in 34 patients and distant metastasis in 28 patients. LRR and distant metastasis were more commonly found in females, age > 40 years, Clark's level IV and V, Breslow's depth > 4 mm, patients with lymph node involvement and extra-capsular spread. CONCLUSION: The age, sex, site, thickness of lesion, involvement of lymph node, and extra-capsular spread were important factors in predicting LRR and distant metastasis. Distant metastasis was also more commonly found in patients with LRR.

Male breast cancer in Indian patients: is it the same?

BACKGROUND: Cancer of the male breast accounts for about 1% of all malignancies in men and 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. This study was done to analyse the demographic data, management and survival of male breast cancers in Indian subset of patients and compare it with that of western literature. MATERIALS AND METHODS: A 10 year (2001-2010) retrospective study of all male breast cancers was done. Data regarding the incidence, presentation, histopathology, stage and grade of tumor, management and outcome of patients were analysed. RESULTS: 26 cases of male breast cancer were encountered. This comprised 0.4% of all breast cancers seen in our department during the 10 year period. The ages of patients ranged from 45-75 years with a mean age of 57 years. Family history was present in 4 patients. Clinically, symptoms included self-detected lump in 23 (88.5%) patients, nipple retraction in 12 (46.1%) and pain in 12 (46.1%). All cases were unilateral (16 on right, 10 on left). Disease most commonly involved central quadrant (9 patients). Grade 3 disease was found in 13 patients and Stage 3 disease was most commonly encountered (13 patients). None of our patients received neo adjuvant chemotherapy. 20 (76.9%) patients had modified radical mastectomy and 6 (23.1%) had radical mastectomy. Most of our patients were hormone receptor positive (21 patients). Bilateral orchidectomy, Adjuvant chemotherapy, Adjuvant radiotherapy and Tamoxifen were offered in 3 (11.5%), 16 (61.5%), 17 (65.4%) and 15 (57.7%) patients respectively. Follow up ranged from 1-59 months. CONCLUSION: Male breast cancer is rare in our centre. Late presentation with advanced disease is a common feature in our environment. Further multiinstitutional, prospective studies are needed for better understanding of management of male breast cancers in Indian subset of patients.

Pheochromocytoma in Indian patients: a retrospective study.

AIM: To review the clinical experience on pheochromocytoma in Indian subset of patients. MATERIALS AND METHODS: Ten patients diagnosed with pheochromocytoma between 2001 and 2010 at our institute were retrospectively studied for clinical, laboratory, radiological and surgical data. RESULTS: A total of 10 patients (5 females and 5 males) aged between 23 and 64 years diagnosed as pheochromocytoma were managed at our institute. The most frequent symptoms were abdominal pain (90%) and hypertension (50%). The tumor was intra-adrenal in 70% and extra-adrenal in 30%. 20% were on right side and 50% on left side. CT scan of abdomen was the most widely used method for tumor localization. Among laboratory assays, 24-h urinary vanillylmandelic acid (VMA) was the most widely used. None of our patients were found to be associated with hereditary pheochromocytoma syndrome. All hypertensive patients were preoperatively treated with phenoxybenzamine and propranolol. All underwent explorative laparotomy and adrenelectomy. Malignancy was reported in 40% of cases and these received adjuvant radiotherapy. Among hypertensive patients, surgery caused remission of hypertension in 60%. All patients were followed up with 24-h urinary VMA levels and CT scan of abdomen regularly. Survival ranged from 1 to 9 years. CONCLUSIONS: The present study confirms that the clinical presentation of pheochromocytoma is variable and non-specific. Often the tumor is discovered incidentally. Though pheochromocytoma is a rare tumor, proper evaluation, preoperative preparation and complete surgical excision are important for its management.

Gastric pull up reconstruction after pharyngo laryngo esophagectomy for advanced hypopharyngeal cancer.

Hypopharyngeal cancers are uncommon. The management of advanced hypopharyngeal carcinomas has been a difficult problem. Surgical resection has been more successful. While many surgical methods have been used and reported pharyngolaryngo esophagectomy with gastric pull up remains the best option. This study documents our experience with patients who underwent total pharyngolaryngoesophagectomy with immediate gastric pull-up for advanced carcinoma hypopharynx. The clinical data of 17 patients treated with pharyngo-laryngo-esophagectomy for advanced carcinoma of the hypopharynx between 2001 and 2004 was analyzed. All patients had advanced disease and required a gastric pull-up for reconstruction. Data obtained included age, sex, site, stage, post op complication, duration of follow up, recurrence & survival. Average age was 37.7 years and ranged from 27 to 56 years. There were 13 female patients and 4 male patients .13 patients presented with postcricoid tumours and 4 with posterior pharyngeal wall tumors, 13 patients presented with stage 3 tumors and 4 patients presented with stage 4 tumors. Wound infection was present in 2 patients (11.7%), anastomotic leak in 1(5.8%), hypocalcemia in 1(5.8%) and malignant pleural effusion in 1 patient (5.8%). Local recurrence occurred in 1(5.8%) while nodal recurrence occurred in 5(29.4%) patient. The average over all survival in our study was 19.5 months and ranged from 2 to 101 months. The gastric pull-up operation is a useful and effective method for the immediate reconstruction of the advanced hypopharyngeal malignancy.

The microbial flora associated with oral carcinomas.

OBJECTIVE: Changes in the microbial flora on the oral mucosa after cancerous alteration may lead to both local and systemic infections. In this study, we assessed the microbial flora associated with the surfaces of oral squamous cell carcinoma. A comparative evaluation of these microbial contents was made with that of the contralateral healthy mucosa and control (healthy) mucosa. We also assessed the microbial flora from the saliva culture in subjects with oral squamous cell carcinoma and healthy controls. METHOD AND MATERIALS: The case control study was made up of 30 subjects with oral squamous cell carcinoma as the study group; 30 healthy age-, sex-, habit-, and dentition-matched subjects served as the control group. In the study group, microbial samples were collected from the carcinoma site, contralateral healthy mucosa, and saliva, whereas in the control group, samples were collected from the healthy mucosa and saliva. These samples were stored on ice and subsequently transported to the laboratory in 2 mL of thioglycollate transport media, where the microbial cultures were carried out. RESULTS: Oral squamous cell carcinoma sites harbor significantly more microbial flora (bacteria and yeasts) compared to those of healthy mucosa (control group). The microbial flora predominantly isolated from the carcinoma site were Streptococcus species, Staphylococcus species, Moraxella species, Enterococcus feacalis, Aerobic spore bearers, Klebsiella species, Citrobacter species, Proteus species, Pseudomonas species, and Candida albicans. The median number of colony forming units (CFU)/mL at carcinoma sites (3.85 x 105 CFU/mL) was significantly higher than that of the healthy mucosa (0.571 x 105 CFU/mL; P = .0000, Wilcoxon nonparametric test). Similarly, in saliva of carcinoma subjects, the median number of CFU/mL (2.408 x 105 CFU/mL) was significantly higher than that of saliva in control subjects (0.78 x 105 CFU/mL; P = .0000, Wilcoxon nonparametric test). CONCLUSION: The present study clearly indicates that the subjects with oral squamous cell carcinoma harbor significantly more microbial flora. Emphasis has to be given to preventing microbial flora in the oral cavity and treating these patients with appropriate antimicrobial agents, thus reducing their morbidity.