COVID-19 Impact on Newly Diagnosed Breast Cancers at Regional Cancer Centre, Thiruvananthapuram-An Audit.

Geethu Babu The coronavirus pandemic has created havoc in every aspect of life including cancer care and was declared a pandemic. This audit was conducted to study the impact of the pandemic on diagnosis and treatment of newly diagnosed breast cancer patients at a tertiary cancer center in South India. A total of 1,647 patients who registered at Regional Cancer Centre (RCC), Thiruvananthapuram, Kerala, India for breast cancer during the period April 1, 2020, to September 30, 2020 (COVID-19 period) as well as April 1, 2019, to September 30, 2019 (pre-COVID-19 period) were included in the study. Data regarding the geographic distribution, stage at presentation, time factors for reporting for care, diagnosis, and treatment, referral for care elsewhere were collected and analyzed. The study was approved by the Institutional Review Board. Means and ranges were calculated for continuous type variables, and numbers and percentages for categorical variables. To determine whether there were significant differences between the two groups, independent t -test was used for continuous variables and chi-square test for categorical type of variables. A notable reduction (36%) in newly diagnosed breast cancer patients was seen in 2020 when compared with 2019. There was a significant difference in the geographic distribution of patients in both cohorts ( p = 0.001) and a notable reduction in the number of patients reporting to RCC for treatment from the northern districts of Kerala (81%) and outside Kerala (89.5%). There was no significant difference in the time (in weeks) since symptom onset and reporting to hospital or the clinical stage at diagnosis between the groups. Also, coronavirus disease 2019 (COVID-19) did not seem to negatively impact time intervals between date of registration and pathological diagnosis or start of primary treatment. More patients received neoadjuvant systemic therapy during 2020 compared with 2019, and this difference was statistically significant ( p = 0.004). There was no difference in the type of surgery (breast-conserving surgery vs. modified radical mastectomy). The results demonstrate that COVID-19 did not appear to negatively impact the diagnosis and treatment of newly diagnosed breast cancer patients. However, this is largely attributable to the significantly less number of patients who registered, for whom the departments were able to maintain timely cancer care despite the difficult pandemic times. Significantly more patients received neoadjuvant systemic therapy in 2020.

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.

Co-expression of galectin-3 and vimentin in triple negative breast cancer cells promotes tumor progression, metastasis and survival.

BACKGROUND: Lack of druggable targets and complex expression heterogeneity of known targets is common among TNBC subtypes. An enhanced expression of galectin-3 in TNBCs has already been documented. We have observed a tumor progression-dependent galectin-3 expression in TNBCs compared to adjacent epithelium and non TNBCs. OBJECTIVE: To unravel the association of galectin- 3 in tumor progression, aggressiveness and drug resistance in TNBC patients. METHODS: Galectin-3 expression in 489 breast cancer tissues was correlated with clinicopathological features and the results were validated in cell lines and mouse model by silencing galectin-3 using shRNA and the proteins were profiled by western blot and qRT-PCR. Protein interaction was analyzed by GFP Trap and Mass spectrometry. RESULTS: Galectin-3 expression correlated with tumor stage in TNBC and a lower galectin-3 expression was associated with poor patient survival. The positive correlation between galectin-3, vimentin and CD44 expression, pinpoints galectin-3 contribution to epithelial to mesenchymal transition, drug resistance and stemness. Vimentin was found as an interacting partner of galectin-3. Duplexing of galecin-3 and vimentin in patient samples revealed the presence of tumor cells co-expressing both galectin-3 and vimentin. In vitro studies also showed its role in tumor cell survival and metastatic potential, elementary for tumor progression. In vivo studies further confirmed its metastatic potential. CONCLUSIONS: Tumor progression dependent expression pattern of galectin 3 was found to indicate prognosis. Co-expression of galectin-3 and vimentin in tumor cells promotes tumor dissemination, survival and its metastatic capability in TNBCs.

Effects of Revision Surgery and Surgical Margins on Outcome of Peripheral Soft Tissue Sarcomas: Experience from a Tertiary Cancer Care Centre.

INTRODUCTION: The purpose of this study is to assess the impact of revision surgery, after unplanned excision, on oncological outcome and surgical morbidity in soft tissue sarcomas and also to assess the relation between margin status and oncologic outcome. MATERIALS AND METHODS: We undertook a retrospective analysis of prospectively maintained database of 153 patients with peripheral soft tissue sarcomas treated in our institute from 2006-2010. RESULTS: Postoperatively, 111(72.5%) patients had negative margins, 20(13.1%) had close margins and 22(14.4%) had planned positive margins. Local recurrence rate was 19.8% in patients with negative margins and 28.6% for patients with close or positive margins (p= 0.007). There was no statistically significant difference in rates of distant metastases (18.9% vs 21.4%, p value 0.56) and five-year overall survival (82.5% Vs 79.8%, p value 0.41) between margin negative and close/positive groups. The five-year overall survival rates were 80.4 vs 77.8% (p =0.42) and five-year disease-free survival rates were 72.4% vs 70.2% (p=0.3), in the revision surgery group and primary surgery group respectively. CONCLUSION: Margin status after excision of soft tissue sarcoma is not a direct predictor for overall survival or distant metastasis. Revision surgery after an unplanned excision does not carry worse survival compared to primary surgery group.

Is Young Age an Independent Prognostic Factor in Carcinoma Breast? A Single-Institution Retrospective Comparative Study from South India.

Breast cancer is the most common cancer in women globally(1). It is usually a disease of old age. The incidence of breast cancer in females younger than 40 years is as low as 0.5%. Disease in patients with age less than or equal to 40 years at diagnosis is usually considered a young breast cancer(2). Occurrence of more adverse pathological features like triple negative and Her2 positive breast cancer as well as lacking reliable screening methods in young women leads to the poor prognosis in this group of patients(3). In the present study we aim to find the clinical and pathological characteristics of breast cancer in young women and their survival outcome for 5 years comparing the same with those characteristics of the older patients. Patients with nonmetastatic carcinoma breast who had registered at Regional Cancer Centre, Trivandrum, during the year 2012 were selected for the study. Patient's details including the clinicopathological features, treatment details, oncologic outcomes including recurrence, and survival data until 31 July 2019 were collected from treatment files kept in the hospital and via telephonic interview. Kaplan-Meier method was employed for survival analysis. Survival comparison was done using the log-rank test. Cox proportional hazards regression analysis was done for assessing the risk. Out of 1611 curatively treated patients with carcinoma breast, 281 (17.44%) were young breast cancer (equal to or less than 40 years). The median follow-up period was 82 months. Median age of diagnosis was 51.3 years. Young patients presented with larger tumour size, but nodal stage and composite stage, were not different. They had more TNBC status, 35% vs. 24%, p = 0.001. Young patient group had a drop in 5-year OS but statistically insignificant (75.9% vs. 82.5%, p = 0.179) and marginally significant drop in DFS (68.1% vs. 73.8%, p = 0.064). The proportion of young breast cancer is very high in the Indian population. Age is not an independent risk factor for worse prognosis. T and N stage, Her2nue status, and adequacy of nodal clearance are the most important independent risk factors deciding the 5-year OS.

Limberg Flap in Breast Oncoplasty for Carcinoma Breast Revisited-a Tertiary Cancer Centre Experience.

Limberg flap is currently not commonly used in breast oncoplasty. We present our experience with Limberg flap reconstruction in breast cancer patients who underwent breast conservation surgery. This study was conducted at a tertiary cancer centre in Kerala, India. We reviewed the records of patients with breast cancer who underwent Limberg flap reconstruction with breast conservation surgery from 1st January 2020 to 31st October 2021. Data collected included age, quadrant of tumour, side of tumour, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications following surgery and breast deformity following surgery. Seventeen patients underwent Limberg flap reconstruction during the study period. The median age of the patients was 51 years. The commonest stage was cT1N0M0. Twelve patients underwent primary surgery and 5 post neoadjuvant chemotherapy. No patient had postoperative flap complications or breast deformity. Limberg flap is simple, versatile and robust and should be a part of the armamentarium of breast surgeons.

Quality of Life Post Breast Cancer Surgery: Comparison of Breast Conservation Surgery versus Modified Radical Mastectomy in a Developing Country.

Introduction Breast cancer survivors are the largest group of female cancer survivors. Oncologic breast surgery can have a profound impact on a woman's body image and sense of self that can significantly affect their quality of life (QOL). The paucity of data about the effect of type of surgery on QOL of Indian breast cancer survivors has led to this study. Materials and Methods This prospective study included consecutive female early breast cancer patients who underwent primary surgery, that is, breast conservation surgery (BCS) or modified radical mastectomy (MRM) from January 1, 2015 to December 31, 2015. The primary objective was the comparison of QOL using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and EORTC QLQ-BR 23 between the two groups at 6 months and 1 year postsurgery with the baseline. Results One hundred and thirty-eight patients were included of which 62 underwent BCS and 76 underwent MRM. BCS patients fared better with respect to physical functioning, dyspnea, fatigue, appetite loss, and body image at 6 months ( p < 0.05) as compared with MRM. At 1 year postsurgery, BCS patients fared better with respect to physical functioning, role functioning, global health status, body image, sexual enjoyment, and dyspnea, while MRM patients fared better in emotional functioning and future prospectives ( p < 0.05). Conclusion Patients undergoing BCS have a better QOL with respect to various functional and symptom scales at 6 months and 1 year. However, patients undergoing MRM perform better in terms of future perspective and emotional functioning at 1 year.

Cancer relapse in surgical patients who received perioperative transfusion of blood and blood products: A case-control study.

BACKGROUND AND AIMS: Immunomodulatory consequences of allogeneic blood transfusion may outweigh the advantages of improved oxygen delivery and tissue perfusion, especially in patients with cancer. In colorectal cancer, there is evidence of cancer relapse in patients who received transfusion. This retrospective analysis was undertaken to evaluate the relationship between perioperative blood transfusion and cancer recurrence in patients undergoing oncosurgery. METHODS: In this case-control study, we retrospectively analysed the case sheets of 194 patients who had perioperative transfusion and underwent cancer surgery from March to December 2013(Study group, Cases). They were compared with controls matched for cancer site and TNM staging who did not receive perioperative transfusions (Control Group, Controls). We intended to find out if the Study group had any increased risk of cancer relapse compared with the controls. Records from the institute cancer registry were analysed in 2018 to give a follow-up period of 5 years. Continuous variables were analysed using Student's T test and Mann Whitney U test for normally distributed and skewed data respectively. For Categorical data Fisher's exact test and Chi square test were applied. The risk for recurrence was estimated using odds ratio. RESULTS: The recurrence rate in cases and controls was 53.09% and 19.59% respectively and the odds ratio, 4.647 (CI: 2.954, 7.309). In Cases, significant relapse was noted for carcinomas of ovary, colorectal, bladder, larynx, head of pancreas and liver. CONCLUSION: In surgical oncology patients, ABT is associated with greater rate of recurrence.

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.