Impact of Level of Surgery on the Functional Outcomes in Patients with Lower Extremity Bone Tumors Undergoing Amputation Versus Limb Salvage Surgery.

Limb salvage surgery is the preferred treatment for bone tumors in the current surgical practice. The aim of this study was to compare the functional outcomes between amputation and limb salvage surgery based on the level of surgery at two levels: knee and hip. A single institutional analysis of 137 patients with lower extremity bone tumors was done between 2014 and 2020. Eighty-seven patients treated with amputation were compared with 50 patients treated with limb salvage surgery based on following variables: age, gender, histology, anatomic site, and MSTS score. The mean MSTS scores were fairly better in patients who underwent surgery at knee level compared to those who underwent surgery at hip level. The mean MSTS score at 1-year follow-up was 22.0 in amputation group compared to 22.4 in limb salvage group, whereas at 2-year follow-up was 24.1 in amputation group compared to 25.1 in limb salvage group. At knee level, functional outcomes were similar after amputation and limb salvage. At hip level, patients undergoing amputation had poorer MSTS scores compared to limb salvage surgery at 2-year follow-up (p = 0.04). The functional outcomes for patients undergoing surgery at knee level were similar irrespective of type of surgery. At longer follow-up, patients undergoing amputation at hip level had a poorer functional outcome compared to limb salvage surgery. Although limb salvage was associated with similar MSTS scores when compared with amputation, it produced a better functional outcome especially for proximally located tumors.

Prognostic Value of Tumor Markers in Gastric Cancer: A Tertiary Cancer Centre Experience.

OBJECTIVES: Gastric cancer is a heterogeneous malignancy in terms of stage-wise prognosis. This study aimed at finding any prognostic significance of preoperative carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 in resectable gastric cancer. METHODS: A total of 57 patients at Kidwai Memorial Institute of Oncology, Bengaluru, India from January 2022 to March 2023 were included in this observational prospective study. Included patients had a resectable tumor at clinical staging. Patients were divided into two categories (raised and non-raised) based on serum tumor marker (CEA and CA 19-9) levels. Their relationship with clinicopathological features was studied. The association was studied using chi-square test, and p-value <0.05 was considered significant. RESULTS: The mean age of the study group was 55.47 years with male predominance (63.2%, n=36). Raised CEA and CA 19-9 were seen in 15.8% (n=9) and 10.5% (n=6) patients, respectively, while both markers were raised in 5.3% (n=3). Raised CEA was found significantly associated with grade 3 adenocarcinoma stomach (OR 7.825, 95%CI: 1.374-44.562; p= 0.020) and intraoperative finding of inoperability due to occult intra-abdominal disease (p<0.05). CA 19-9 (pre- and post-operative levels) had no statistically significant association (p>0.05) with the grade of adenocarcinoma. CONCLUSION: This study indicates a benefit in estimating CEA for the prediction of prognosis in gastric cancer. CEA levels have been found to predict chances of finding occult intra-abdominal metastasis in gastric cancer.

Primary Hyperparathyroidism: Is Image Localization Alone Sufficient to Ensure Long-Term Cure in Unifocal Disease?

INTRODUCTION: Advances in imaging have facilitated precise preoperative localization and focused resection of hyperfunctional parathyroids in primary hyperparathyroidism (PHPT). Combining imaging techniques or a "dual" approach, when concordant, improves adenoma-localizing accuracy above individual modalities. This study sought to assess biochemical cure and failure rates (persistence or recurrence) of surgery directed by dual imaging alone in PHPT. METHODOLOGY: This observational, single-center analysis comprised 31 patients diagnosed with PHPT and imaged with both ultrasound (USG) of the neck and sestamibi scintigraphy. The extent of surgery was based solely on inter-modality concurrence for adenoma localization; imaging-concordant patients underwent focused parathyroidectomy, whereas discordant patients necessitated neck exploration (with extent altered according to scintigraphic lesion lateralization). No intraoperative localizing adjuncts were used. RESULTS: Twenty-three patients had concordant imaging, of which 19 underwent focused exploration, with sensitivity and positive predictive value (PPV) for dual imaging of 100% and 95.7%, respectively. The overall sensitivity and PPV were 92.9% and 89.7% for USG alone and 100% and 93.6% for scintigraphy, respectively. The mean age and prevalence of thyroid disease were significantly higher in the discordant group. All patients achieved postoperative normocalcemia. There were no cases of persistent or recurrent hyperparathyroidism on follow-up. CONCLUSIONS: In the imaging-concordant setting, focused surgery may be safely performed with the omission of other adjuncts for localization. Older age and concomitant thyroid pathology predispose to discordant imaging and are risk factors for surgical failure when attempting an image-directed approach. Neck exploration is an alternative in these patients with excellent cure rates and acceptable morbidity.

A Study of Morphological Characteristics of Lung Fissures and Trachea in the Indian Population.

Tracheal length and lung anatomy have been rarely studied; however, the anatomy of the lung has been shown to vary significantly. Moreover, the surgery regarding trachea are few, and hence the surgeons do not have extensive experience in the trachea. OBJECTIVE: We aimed to study the variations of the lung anatomy and the relation between tracheal length and body height in the Indian population. MATERIALS AND METHODS: This is an observational study to observe the tracheal length in relation to body height and sex and gross morphological anatomy of the lung in 70 cadavers. The data was collected from the forensic department of Bangalore Medical College and Research Institute (BMCRI), and further analysis was done at Kidwai Memorial Institute of Oncology. RESULTS: Deviation from normal lung morphology was seen in 37.86% of the specimens studied. The tracheal length (average, 9.97 cm) correlated with the body length (average, 147.02 cm) with a Pearson coefficient of 0.806 (p value=0.001) Conclusion: The study of lung fissure morphology guides clinicians in understanding and planning lung disease treatment, especially lobectomy/segmentectomy surgeries. The information of the average length of the trachea with respect to body height in a given ethnicity will help during endotracheal intubation and tracheal surgical planning.

Reverse Axillary Mapping in Breast Cancer Using Blue Dye: A Tertiary Setup Experience.

The concept of reverse axillary mapping originated with the main purpose of reducing lymphedema. In this study, we test the advantage of reverse axillary mapping to delineate the arm-draining lymph nodes and their involvement in various stages of breast carcinoma. In this study, we also attempt to redefine the template for axillary dissection in breast cancer. During the period of September 30, 2020, to August 30, 2021, 46 patients were recruited to undergo a procedure in which isosulfan blue dye was injected into the upper arm and the axilla was explored to isolate the lymph nodes. The lymph nodes were submitted for examination histopathologically. The results conclusively showed that axillary lymph node metastasis was only influenced by the advanced stage of the disease (p=0.014) and the visualization of the lymphatics was independent of the stage, type of surgery, decubitus, or age. The study conclusively shows that attempts to preserve the upper limb-draining nodes in advanced stages would be futile and the preservation of such lymph nodes should be limited to the early stages of breast cancer.

Contemporary Surgical, Oncological, and Survival Outcomes of Pancreaticoduodenectomy for Periampullary Tumours: a 5-Year Experience from Tertiary Cancer Center.

With advances in surgical management of pancreaticoduodenectomy (PD), mortality rate for PD has been reported to be less than 5%. Postoperative pancreatic fistula (POPF) remains a major complication and morbidity after PD with incidence of up to 40%. This is a retrospective analysis of patients who underwent PD in a tertiary cancer referral center in southern India. Data was collected for the patients operated during the period from Jan 2014 to Dec 2018. Surgicopathological, oncological, and survival outcomes were described. Of 76 patients presumed as operable, 16 were excluded and data analyzed for 60 patients. Forty-four percent underwent classical Whipple's PD and 56% pylorus-preserving PD. The most common postoperative complications were wound infection (25%); pneumonia (20%); clinically relevant POPF (13%); and delayed gastric emptying (19%). Thirty-day in-hospital mortality was 5%, 90-day mortality was 8.3%, and fistula-related mortality was 1.6%. Ampullary cancer was the most common histology. Three-year survival rate was 23.3% with a mean overall survival of 33.2 months with significantly better survival in the node negative than positive group (41.3 vs 20.5 months, P = 0.003) and significantly lower survival in pancreatic head cancer than other tumor histologies (16.6 vs 37.3 months, P = 0.002). Multivariate analysis has shown pancreatic head histology (HR = 2.38, 95% CI (1.08-5.26), P = 0.033) and nodal positivity (HR = 2.38, 95% CI (1.27-4.44), P = 0.007) as poor prognostic factors. Pancreaticoduodenectomy is a safe operation in experienced hands. Adhering to a meticulous adaptable reproducible anastomotic technique with standard perioperative management strategies significantly decreases the operative morbidity and mortality.

Operative Outcomes of Minimally Invasive Esophagectomy versus Open Esophagectomy for Resectable Esophageal Cancer.

Background There is a recent rise in the incidence of esophageal carcinoma in India. Surgical resection with or without neoadjuvant chemoradiation is the current treatment modality of choice. Postoperative complications, especially pulmonary complications, affect many patients who undergo open esophagectomy for esophageal cancer. Minimally invasive esophagectomy (MIE) could reduce the pulmonary complications and reduce the postoperative stay. Methodology We performed a retrospective analysis of prospectively collected data of 114 patients with esophageal cancer in the department of surgical oncology at a tertiary cancer center in South India between January 2019 and March 2020. We included patients with resectable cancer of middle or lower third of the esophagus, and gastroesophageal junction tumors (Siewert I). MIE was performed in 27 patients and 78 patients underwent open esophagectomy (OE). The primary outcome measured was postoperative complications of Clavien-Dindo grade II or higher within 30 days. Other outcomes measured include overall mortality within 30 days, intraoperative complications, operative duration and the length of hospital stay. Results A postoperative complication rate of 18.5% was noted in the MIE group, compared with 41% in the OE group ( p = 0.034). Pulmonary complications were noted in 7.4% in the MIE group compared to 25.6% in the OE group ( p = 0.044). Postoperative mortality rates, intraoperative complications, and other nonpulmonary postoperative complications were almost similar with MIE as with open esophagectomy. Although the median operative time was more in the MIE group (260 minutes vs. 180 minutes; p < 0.0001), the median length of hospital stay was shorter in patients undergoing MIE (9 days vs. 12 days; p = 0.0001). Conclusions We found that MIE resulted in lower incidence of postoperative complications, especially pulmonary complications. Although, MIE was associated with prolonged operative duration, it resulted in shorter hospital stay.

Survival Outcomes in Patients with Thymoma after Thymectomy in an Indian Scenario.

Thymomas are relatively slow growing with late presentation. Because of rarity and underreporting in India, there is an unmet need for evaluating the patient characteristics and assessing the factors affecting survival for standardizing the ideal modality of treatment in Indian population. A retrospective analysis of 96 patients with thymoma was done between 1998 and 2018. Patient characteristics, histopathological characteristics, operative outcomes, local recurrences, and survival outcomes were recorded. Survival analysis was done using Kaplan-Meier method, and statistical data were analyzed using SPSS version 25 (IBM). The incidence of thymoma was relatively high in 6th decade with no sex predilection. Common presenting symptoms were cough and dyspnea. Myasthenia gravis was noted in 30.2%, which resolved after thymectomy in 65.5% of patients. Most patients presented with Masaoka stages I and II, and predominant WHO histological types were B1 and AB. Complete resection was done in 69.8% cases, and local recurrence was noted in 15.6%. Median sternotomy was the most frequently used approach for thymectomy. The 5-year overall survival was 76%, with an excellent 5-year survival of 95% and 86% in stages I and II patients. Masaoka stage, WHO histologic type, completeness of surgery, and local recurrence did affect the survival significantly. Masaoka stages III and IV, histological type B3, incomplete resection during surgery, and presence of local recurrence did independently predict a worse overall survival.

Sentinel Lymph Node Biopsy in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy-an Indian Perspective.

Sentinel lymph node biopsy (SLNB) alone in early breast cancer is an established standard of care. However, the same results have not been replicated in locally advanced breast cancer (LABC) after neoadjuvant chemotherapy (NACT). We aim to examine the feasibility of SLNB in LABC patients post NACT to determine identification rates (IR) and false negative rates (FNR). This was a single tertiary cancer center-based prospective study from February 2017 to November 2018. Forty-four patients with LABC (T3, T4 with N0 or N1) were studied and response after NACT was assessed. Only those patients who were N0 or who converted from N1 to N0 after NACT were included. Those patients who remained node positive after NACT directly proceeded with axillary dissection without SLNB and were excluded from the study. Demographic and clinical data is expressed in ratios and percentage and presented in table format. The median age at the time of study was 45.18 years. Most of the patients had T3 and above (97.7%) and N1 (86.3%) disease at the start of neoadjuvant therapy. The mean number of axillary lymph nodes dissected was 13.97. Dual method of sentinel lymph node mapping (methylene blue dye and radiolabeled colloid) was used in 26 (59.1%) patients. At least 1 SLN was identified in 86.4% patients with 100% identification in those patients in whom the dual method of SLN mapping was used. Median of 2 SLN was removed. Overall, false negative rate was 21.4%. FNR was high with the single method of SLN mapping (50% and 33.3% with methylene blue and radioactive colloid respectively) while it was considerably low when both were used simultaneously (11%). An average of 2 (range 0-4) SLN were identified and FNR were zero when 2 or more SLN were identified. Our study shows that SLNB in patients with LABC post NACT though viable cannot be recommended at present due to unacceptable high FNR. However, this should not dissuade us from exploring recurrence-free survival and overall survival associated with such IR and FNR albeit strictly under a clinical trial setting.

Urachal adenocarcinoma surgical management - Emphasis on enbloc umbilectomy and urachal remnant excision with negative margins.

Urachal adenocarcinoma is a rare malignant epithelial cancer. It usually presents in advanced stages. We present a 35-year-old female with urachal adenocarcinoma presented with an anterior abdominal wall swelling and ulcer managed surgically with wide excision of anterior abdominal wall along with intra-abdominal tumour mass with umbilectomy and contiguous urachal remnant excision with abdominal wall reconstruction with mesh repair who was doing well at one year follow up. We also present a brief review regarding pathologic criteria, evolution of various staging systems and surgical aspects of urachal adenocarcinoma.

Perioperative Artificial Enteral Nutrition in Malnourished Esophageal and Stomach Cancer Patients and Its Impact on Postoperative Complications.

Cancer is responsible for approximately 13% of all causes of death worldwide, and 20% of cancer patients die because of malnutrition and its complications. Malnutrition is common in cancer of stomach and esophagus. Although it is widely accepted that malnutrition adversely affects the postoperative outcome of patients, there is little evidence that perioperative nutrition support can reduce surgical risk in malnourished cancer patients. This prospective study was carried out from December 2016 to July 2017 at the Kidwai Memorial Institute of Oncology, Bengaluru. After stratified for age, sex, and tumor localization, patients were selected non-randomly and assigned to study (n = 30, 14 women, 16 men) and control group (n = 30, 14 women, 16 men) as alternate patients. Within 48 h of admission, patients underwent nutritional assessment by the subjective global assessment. Perioperative nutrition was administered in the study group by enteral route only. Patients had a functioning gastrointestinal tract, and they received enteral nutrition (EN). Target intake of non-protein (25 kcal/kg per day) and protein (0.25 g nitrogen/kg per day) was provided using available enteral formulas. This was supplementary to standard hospital diet. Nutritional re-assessment after 15 days of intervention showed significant change in nutritional status, which was measured as gain in weight for each patient. There were significant differences in the mortality and complications between the two groups. The total length of hospitalization and postoperative stay of the control patients were significantly longer than those of the study patients. In conclusion, perioperative nutrition support can decrease the incidence of postoperative complications in moderately and severely malnourished gastric and esophageal cancer patients. In addition, it is effective in reducing mortality. Enteral nutrition support alone can be used in the management of malnourished patients undergoing gastric and esophageal surgery.

Perioperative Mortality in Cancer Esophagus-a Case Control Study at a High-Volume Regional Cancer Center in South India.

Surgery for esophageal cancers carries high rates of morbidity and mortality despite improvements in perioperative care especially with increasingly safe anesthesia and postoperative ICU care. A case control study was conducted on 713 patients operated for esophageal cancer over a period of 8 years (2009-2016). Multiple preoperative, intraoperative, and postoperative clinical and laboratory parameters were compared between patients who succumbed to the surgery, i.e., 30-day mortality, and those who did not. Of the preoperative parameters, age > 58.5 years (p = 0.01), history of dysphagia with significant weight loss (p = 0.028), diabetes (p = 0.002), ischemic cardiac disease (p = 0.0001), low FEV1 < 69.5% (p = 0.036), preoperative length of hospital stay > 6.94 days (p = 0.001), involvement of gastroesophageal junction (p = 0.04), and ASA score > 2 (p = 0.002) were significantly associated with perioperative mortality. Intraoperatively, blood loss (p = 0.003), intraoperative (p = 0.015) and postoperative (p = 0.0001) blood transfusion, splenectomy (p = 0.0001), and excessive intraoperative intravenous fluids (p = 0.003) were associated with mortality. Decreased postoperative day 1 serum albumin level < 2.38 mg/dl (p = 0.0001), increased ICU stay > 7.32 days (SD+/- = 6.28, p = 0.03), number of positive lymph nodes > 2.97 (SD+/- = 4.19, p = 0.013), conduit necrosis (p = 0.0001), recurrent laryngeal nerve palsy (p = 0.013), pulmonary venous thromboembolism (p = 0.0001), multiple organ dysfunction syndrome (p = 0.0001), LRTI (p = 0.0001), arrhythmia (p = 0.005), sepsis (p = 0.0001), and ARDS (p = 0.0001) were the postoperative complications that were significantly associated with mortality. Comprehensive patient care involving preoperative optimization, improved surgical skills, rigorous intraoperative fluid management, and dedicated intensive care units will continue to play a major role in further minimizing mortality and morbidity associated with esophageal cancer surgeries.

Seminoma of undescended testis with urinary bladder metastasis: A case report with review of literature.

Cryptorchidism is the most common predisposing factor in the development of testicular germ cell tumors. Seminoma is the most common malignancy developing in a cryptorchid testis, usually has lymphatic but rarely hematogenous metastasis. The Urinary Bladder is an extremely rare site of metastasis of seminoma metastasis. A 29-year-old male patient presented to us with a history of infertility and an intra-abdominal mass. He was investigated and treated and was found to have an intra-abdominal seminoma with synchronous urinary bladder metastasis. He was treated with appropriate chemotherapy and continues to be in good health.

Inguinal Lymph Nodes in Carcinoma Penis-Observation or Surgery?

INTRODUCTION: In Indian sub-continent the presentation of carcinoma penis is variable. Mostly presents with palpable inguinal lymph nodes but not confirm of metastases. AIM: To evaluate whether all clinically positive nodes are metastatic and decide when to address inguinal lymph node. MATERIALS AND METHODS: A retrospective observational study on carcinoma penis from a regional cancer centre of south India over a period from 2001 to 2012. All the clinical, investigational, operative, pathology details and follow-up data were collected from patient records. RESULTS: Two hundred and thirty cases of carcinoma penis have been identified and 112 cases had clinically positive nodes. In 74 cases fine needle cytology was positive for malignancy and they have been addressed with block dissection with surgery of primary lesion. At two years follow up, 70 patients were identified with inguinal lymph node metastasis and block dissection was performed and all was were positive for malignancy on histology. The rate of recurrence is related to the T stage of the primary tumour. CONCLUSION: It can be concluded that elective surgery is appropriate for palpable inguinal lymph nodes and prophylactic nodal dissection in high risk cases of carcinoma penis.

Castleman's disease of the pleura.

Castleman's disease is a rare benign disease of the lymph nodes. Its origin from the pleura is rare. Surgical excision, when feasible, appears to provide good results. We encountered a patient who had the disease arising from the parietal pleura. We present the clinical scenario, investigations, and our management of the patient.