The real-world experience with nivolumab in previously treated patients with advanced non-small cell lung cancer from a cancer center in India.

BACKGROUND: PDL-1 inhibitors have emerged as the new standard of care for second line treatment of NSCLC. METHODS: Eligible patients included, histologically proven NSCLC, ECOG (Eastern Cooperative Oncology Group) performance status of 0, 1 or 2, age 18 years and above, availability of pre-treatment tumor specimen, adequate end organ function, at least one prior platinum-based therapy. Patients who received a minimum of 6 doses of nivolumab were eligible. RESULTS: Eleven previously treated patients with chemotherapy, started on nivolumab from April of 2016 to December of 2018, were retrospectively studied and analysed. The median age of patients was 58 years. Eight (72.73%) of the eleven patients were male. Seven (63.64%) of the patients were current or former smokers. Majority of patients had non-squamous histology; seven (63.64%) adenocarcinoma and four (36.36%) squamous cell carcinoma. 5 (45.46%) of the patients received one prior therapy, three (27.27%) received two prior therapies, and three (27.27%) received three prior therapies. Four (36.36%) of the patients had brain metastasis. Two (18.18%) of the patients were more than 70 years of age. Median number of cycles of nivolumab administered were 10 (range, 6 to 21). At the time of analysis, the median PFS was 8 months (95% CI, 1.52-14.47) and median OS was 15 months (95% CI, 6.9-23.09). Treatment was well tolerated and generally side effects were grade 1 and grade 2, except two patients who develop grade 3/4 pneumonitis. CONCLUSIONS: This is a real-world study of eleven previously treated patients with chemotherapy, started on Nivolumab from April of 2016 to December of 2018. Although, our sample size was small, our data supports the use of nivolumab as a new treatment option for patients of stage 4 NSCLC.

Pulmonary metastasectomy: review of experience at a tertiary cancer care center.

BACKGROUND: Thirty to 40% of all extra thoracic cancers lead to secondary pulmonary lesions and approximately 20% of these cases feature metastases that are confined to the lungs. There is benefit of pulmonary metastasectomy in a select subset of patients. AIMS: The goal of this study was to evaluate the patient profile, treatment patterns, and outcomes following surgical treatment of lung metastasis and to identify prognostic factors for long-term survival. MATERIALS AND METHODS: Retrospective analysis of a prospectively maintained computerized database at a tertiary cancer care centre was done. 36 patients underwent curative resection for isolated pulmonary metastasis from January 1999 to December 2009. All metastasis were detected by non-contrast CT scan of the chest. Lung function tests were performed in all patients. Posterolateral thoracotomy was performed for resection of pulmonary metastasis by lung sparing procedures. A routine protocol of complete resection of all visible and palpable lung metastasis with a margin of 0.5 to 10 mm was followed in all patients. Staged thoracotomy was done for bilateral metastases. All palpable nodules were resected by wedge resection except in one case where pneumonectomy was done to achieve R0 resection. All patients underwent complete resection. CONCLUSIONS: Disease-free interval of more than 1 year along with less than 2 malignant nodules in patients with non-visceral pulmonary metastasis are variables identified in the present study which have enabled pulmonary metastasectomy to be offered as a safe therapeutic lifeline to patients.

Laparoscopic Supracolic Pancreaticoduodenectomy: A Novel Technique For Complete Uncinate Process Resection.

BACKGROUND: Laparoscopic pancreaticoduodenectomy represents one of the most advanced surgical approaches for periampullary and pancreatic head tumors. This article aims to describe the novel technique for complete resection of the uncinate process from supracolic compartment only and summarizes the results from our institute. METHODOLOGY: Retrospective review of prospectively maintained database was performed for patients who underwent laparoscopic pancreaticoduodenectomy from April 2008 to March 2012 at our institute. RESULTS: A total of 38 patients with a mean age of 56.5 years (range: 35-70) underwent laparoscopic pancreaticoduodenectomy with this novel approach. Complete resection of uncinate process was achieved in 33 (86.84%) patients. The mean total operative time and resection time was 231.70 mins (range: 210-450) and 116.50 mins (range: 80-250), respectively. The mean blood loss was 183 ml (range 60-340). Major perioperative morbidity included pancreatic anastomotic leak (n = 3), billiary leak (n = 1) and hemorrhage (n = 1). Mean hospital stay was 14 days (range: 12-25 days). CONCLUSION: This novel supracolic approach for laparoscopic pancreaticoduodenectomy is feasible, safe and less time consuming. This technique can help achieving oncological outcomes comparable to those of the other techniques; though with the minimum invasion. This procedure can be performed conveniently by surgeons with substantial knowledge, experience and skills.

Laparoscopic transvesical approach for vesicovaginal fistula repair.

STUDY OBJECTIVE: To access the technical feasibility of performing laparoscopic repair of vesicovaginal fistula. MATERIAL AND METHODS: We attempted a laparoscopic repair of vesicovaginal fistula in five women with a history of urinary leakage via the vagina after vaginal hysterectomy. Five pelvic ports were used. The surgical procedure was performed using the same principles as for open surgery, i.e., separation of the vaginal wall from the bladder wall, repair of the fistula, and interposition of the omentum. RESULTS: There was early recovery of the patients in terms of continence, with less chance of recurrence. Results were comparable to those with the vaginal approach. CONCLUSION: The use of minimally invasive surgery for vesicovaginal fistula repair helps to ease the suturing deep in the pelvis, and the magnification facilitates good identification of tissues planes and thus better mobilization of the vaginal and bladder walls and decreases postoperative morbidity.

Minimally invasive esophagectomy in the elderly.

OBJECTIVE: A retrospective analysis of a prospectively maintained database to evaluate our experience in elderly patients (>70 years) undergoing Thoracolaparoscopic esophagectomy for cancer oesophagus. To ascertain whether age, is a limiting factor for patients undergoing minimally invasive esophagectomy. METHODS: All Patients above 70 years of age, referred to the Gastro-esophageal clinic were included in the study. Tumours were staged as per AJCC 6th ed. 2002. Patients diagnosed with T1/2/3, N0/1 lesion of the mid/lower oesophagus (Infra Azygous) and type I and II Gastro esophageal junction tumours were included in the study. Patients with ASA grade IV were excluded. All patients who underwent Thoracolaparoscopic esophagectomy from January 2009 till January 2012 were evaluated for their perioperative outcomes. RESULTS: Sixty eight patients underwent Minimal Invasive esophagectomy from January 2009 to January 2012. There were 45 males and 23 females. The average age in elderly group was 75.76 ± 5.96 years (range 70 to 91). Mean operative time was 178.84 ± 65.26 min, mean blood loss 143.84 ml(range 32-450 ml), mean ICU stay 3.84 days(range 2-11 days) and mean hospital stay was 12.76 days(range 8-21 days). Pneumonia and Cardiac related complications occurred in 10.30 % and 1.47 % patients respectively. None of the procedures required conversion to open thoracotomy. CONCLUSIONS: Thoracolaparoscopic esophagectomy is feasible and surgically safe in elderly patients with low morbidity and mortality. Thus age of a patient should not be considered a limiting factor. ULTRAMINI ABSTRACT: This is an original article about our experience of thoracolaparoscopic esophagectomy for cancer esophagus in elderly patients. After analyzing the data we feel that age of the patient cannot be a truly limiting factor for patient diagnosed of esophageal cancer to undergo minimally invasive esophagectomy.

Efficacy of low level laser therapy on wound healing in patients with chronic diabetic foot ulcers-a randomised control trial.

UNLABELLED: Foot ulcers are serious complications of Diabetes Mellitus (DM) and are known to be resistant to conventional treatment. They may herald severe complications if not treated wisely. Electromagnetic radiations in the form of photons are delivered to the ulcers in laser form to stimulate healing. This study was conducted to evaluate the efficacy of Low Level Laser Therapy (LLLT) in diabetic ulcer healing dynamics. To determine mean percentage reduction of wound area in study and control groups. SETTINGS: KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum. STUDY DESIGN: Randomized-Control Study. METHODS: A total of 68 patients with Type 2 DM having Meggitt-Wagner Grade I foot ulcers of atleast more than 4 weeks duration, less than 6 × 6 cm(2) with negative culture were studied. Patients were randomized into two groups of 34 each. Patients in study group received LLLT with conventional therapy and those in control group were treated with conventional therapy alone. Healing or percentage reduction in ulcer area over a period of 15 days after commencement of treatment was recorded. STATISTICAL ANALYSIS: Unpaired Student T Test and Mann Whitney U test. Mean age of the patients was 50.94 years in control group and 54.35 years in study group (p = 0.065). There was no significant difference between control and study group with respect to mean FBS and HbA1c levels (p > 0.05), suggesting no biochemical differences between two groups. Initial ulcer area was 2608.03 mm(2) in study group and 2747.17 mm(2) in control group (p = 0.361). Final ulcer area was 1564.79 mm(2) in study group and 2424.75 mm(2) in control group (p = 0.361). Percentage ulcer area reduction was 40.24 ± 6.30 mm(2) in study group and 11.87 ± 4.28 mm(2) in control group (p < 0.001, Z = 7.08). Low Level Laser Therapy is beneficial as an adjunct to conventional therapy in the treatment of diabetic foot ulcers (DFU).

Are We Over-treating Neck in Buccal & Alveolo-buccal Cancers: Experience from a Tertiary Cancer Care Center.

Oral cancer is one of the most common types of cancer seen in India with buccal and alveolo buccal regions being the most frequent subsites. A retrospective analysis of buccal and alveolo buccal cancer patients undergoing neck dissection from 1995 to 2009 was performed to analyze the profile of neck dissections and patterns of nodal involvement in these patients. Total 310 neck dissections were done for buccal and alveolo-buccal cancer including 41 (13.2 %) RND, 231(74.5 %) MND and 38 (12.2 %) Supraomohyoid neck dissection (SOHND). Clinically palpable nodes were present in 75.9 % patients but only 117 (38 %) were pathologically node positive. 20 % had occult positive nodes in N0 group. Level I was most commonly involved with 35 % having positive nodes in more than one level. There were no patients with isolated involvement of level IV or V with only 3.9 % patients with involvement of level III. Current guidelines recommend neck dissection in all clinically node positive patients. However, our experience shows that neck is over treated in majority of patients and there is a need to optimize surgical management of neck in these patients.

Chylous fistula after axillary lymph node dissection: incidence, management, and possible cause.

INTRODUCTION: Chylous fistula is a known complication in procedures such as neck dissection and aneurysm surgery. However chyle leak that develops after axillary dissection is a rare phenomenon. In this study we have evaluated the incidence, possible cause, and management of chylous fistula that develops after radical breast cancer surgeries. MATERIAL AND METHODS: Chylous fistula developed in 6 of 1863 patients who underwent axillary dissection. Their records were analyzed in terms of clinical profile and management. A review of the literature regarding the thoracic duct anatomy at its termination was carried out and a hypothesis about the possible cause of chylous leak was suggested. RESULTS: All 6 patients had procedures on the left side and had varied clinical stages and profiles. The chyle discharge was detected intraoperatively during the primary surgical procedure in 2 patients. The other 4 patients presented with chyle in their drains postoperatively. One patient did not respond to conservative management and underwent reexploration to seal the leak. Injury to the thoracic duct or its aberrant branches is apparently not the cause of chylous fistula in the axilla. The injury to the left subclavian duct or its tributary, which drains aberrantly into the thoracic duct through a valveless junction has been hypothesized to be the source of chyle in the axilla. CONCLUSION: Chylous fistula is very unusual after axillary dissection. Most of the chyle leaks in the axilla are manageable through conservative methods; surgical intervention is required rarely in special situations. Injury to the left subclavian duct or its tributary is the possible cause.