Cancer stem cell biomarkers SOX2 and Oct4 in cervical cancer patients undergoing chemoradiotherapy.

BACKGROUND: Cancer stem cell biomarkers SRY (sex-determining region Y)-box 2 (SOX2) and octamer-binding transcription factor 4 (Oct4) account for radioresistance in cervical squamous cell cancers (CSCCs). Their clinical implications are limited and contradictory. METHODS: In this prospective cohort study, we recruited patients with FIGO IB2-IVA CSCC treated with primary chemoradiotherapy on regular follow-up. Tissue biopsy specimens were evaluated for SOX2 and Oct4 expression by immunohistochemistry, quantified by a product of proportion and intensity scores. RESULTS: A total of 59 patients were included. Most had a moderately differentiated (81%), keratinizing (59%) CSCC, and ≥FIGO stage IIB disease (95%). SOX2 expression (high:low 21:38 patients) and Oct4 expression (high:low 4:55 patients) had a significant interrelation (p = 0.005, odds ratio (95% CI) - 1.23 (1.004-1.520)). At a median follow-up of 36 months, the 3-year overall survival (OS) was 60% and 53% for low and high SOX2 expression (p = 0.856), and 54% and 100% for low and high Oct4 expression (p = 0.114). The 3-year disease-frese survival (DFS) was 65% and 50% in the low and high SOX2 expression (p = 0.259), and 59% and 75% for low and high Oct4 expression (p = 0.598). SOX2 expression was the only variable significantly associated with a lower OS and DFS on regression analysis. CONCLUSION: Our study demonstrated a trend toward improved OS and DFS with low SOX2 and high Oct4 expression in CSCC patients undergoing chemoradiotherapy.

Uniportal video-assisted thoracoscopic Ivor Lewis oesophagectomy.

Standard minimally invasive Ivor Lewis oesophagectomy is performed through a multiport technique using carbon dioxide. However, access to video-assisted thoracoscopic surgery (VATS) is increasingly shifting to a single-port approach due to its proven safety and efficacy in lung surgeries. Therefore, the preamble of this submission is to describe, 'How I do differently' uniportal VATS MIO in three major steps: (a) VATS dissection through a single 4-cm incision in a semi-prone position without artificial capnothorax; (b) fluorescence dye to check conduit perfusion and (c) intrathoracic overlay anastomosis with a linear stapler.

Uniportal video-assisted thoracoscopic surgery in semi-prone position utilising direct endobronchial intubation for oesophagus leiomyoma excision.

Leiomyomas are the most common benign tumours of oesophageal smooth muscle origin. In this era of constantly evolving medical technology, video-assisted, robot-assisted and endoscopic approaches are the minimally invasive strategies for the excision of these lesions. Here, we report our modification of this surgery. The lesion was excised with uniportal video-assisted thoracoscopic surgery in a semi-prone position with single-lumen endobronchial intubation.

Quality of Life in Patients with Recurrent Oral Squamous Cell Carcinoma: A Study from India.

Background: Locoregional recurrence of oral cancer causes significant morbidity. This study aims at assessing the functional outcomes of patients undergoing treatment for recurrent oral squamous cell carcinoma. Methods: This study was done in a tertiary care center in North India and includes prospective cohort of 179 recurrent oral carcinoma patients, from September 2017 to September 2018. Patients undergoing treatment of recurrent oral carcinoma were assessed for quality-of-life score at baseline before starting treatment and two months after the completion of the treatment. For the assessment, EORTC QLQH&N35 questionnaire was used. Results: Of 179 patients included, 71 (39.66%) patients underwent salvage surgery and 104 patients (58.10%) received palliative chemotherapy. One hundred and thirty patients could complete the "EORTC-QOL-H&N-35" questionnaire on required two occasions. Forty-nine patients died before completing second questionnaire. More than half (55.6%) of patients who underwent salvage surgery had improved quality of life after the procedures. They have little or no pain in oral cavity, improved swallowing, less odynophagia, improvement in neck and shoulder pain, less problems with the external appearance and socialization, and enjoyed better sexual life. In patients receiving palliative chemotherapy, the quality of life declined in majority (88.1%) of the patients. Conclusions: Although salvage surgery is the best modality of treatment for recurrent oral carcinoma, only about one-third of patients qualify for surgery and enjoy improved quality of life following surgery. On the other hand, in majority of the patients receiving palliative chemotherapy, the quality of life worsened with time and treatment.

Radical surgery for de novo gallbladder carcinoma-Single-center analysis of prognostic factors and survival outcomes from an endemic region.

BACKGROUND AND OBJECTIVE: Gallbladder cancer (GBC) is an aggressive malignancy where curative resection is possible in few and survival is poor. There are limited data on outcomes in patients with de novo GBC from endemic regions undergoing surgery for curative intent. We report survival outcomes in this group of patients from a region with high incidence of disease. METHODS: We reviewed the records of all GBC patients (2014-2018) and included those who underwent radical cholecystectomy (RC) for de novo GBC. Univariable and multivariable analyses were performed to identify factors influencing recurrence and survival. RESULTS: A total of 649 patients with GBC were evaluated for surgery and curative intent surgery was attempted in 246 (38%) patients. Of these 246 patients, RC was performed in 115 patients, with histologically confirmed de novo GBC. Locally advanced disease (≥stage IIIB) was present in 52 (45.2%) patients. Median time to recurrence and overall survival (OS) were 31 and 36 months, respectively. Lymph node positivity (p = 0.005) and grade significantly influenced OS on multivariable analysis. CONCLUSION: Satisfactory survival outcomes are possible after RC for de novo GBC. Extended resections performed in high volume centers combined with appropriate adjuvant treatment can offer significant survival benefits, with acceptable morbidity and mortality rates.

Polymorphous adenocarcinoma of the submandibular gland.

Polymorphous adenocarcinoma (PA) of the salivary glands is a rare malignancy that predominantly affects the minor salivary glands of the palate. Major salivary gland involvement is rare (<5%). The submandibular gland is a highly unusual location for this tumour. Recently, the WHO has updated the classification of salivary gland tumours in which the PA subtype has been modified. We report a very uncommon case of a classical variant of PA involving the submandibular gland in a 49-year-old woman managed at our institute and discuss the most recent pathological criteria for diagnosis, management strategy and prognosis of PA.

Surgical outcomes in oral cancer involving the central arch of the mandible in elderly patients: An institutional experience.

BACKGROUNDS: Oral squamous cell cancer (SCC) is one of the most common cancers. The most common age of presentation is fifth to sixth decade. Management of this disease is dictated by stage, age, and related comorbidities. Elderly patients have their own set of limitations as far as their management is concerned. Carcinoma involving central mandibular arch is a challenging disease for surgeons, especially in the elderly. This article describes our experience with the surgical treatment of oral cancer involving the central arch of the mandible in elderly patients. METHODS: Forty elderly (≥60 years) patients with histologically proven SCC of the oral cavity in which disease was involving the central arch of the mandible, were included in our study. Demographic, clinical, and treatment-related factors were recorded. The outcome was assessed in terms of postoperative complications, recurrence, and patient survival. RESULTS: The median age of the patients was 63 years. The male:female ratio was 7:3. A history of oral tobacco use was present in 95% of patients. The most common site of disease was lower alveolus (80%) followed by carcinoma of the lower lip (20%). Majority of our patients (77.3% [30]) were having Stage IV disease. Mandibulectomy was either segmental (62.5%) or marginal (37.5%). Bilateral neck dissection (37/40, 92.5%) was done in most patients. Among all patients, 62.5% (25) received adjuvant radiotherapy. The local recurrence rate after a median follow-up of 30 months was 15% (6). Two-year disease-free survival and overall survival were 89% and 90%, respectively. CONCLUSION: Central arch of the mandible is a difficult disease to treat. It needs a complex and lengthy reconstructive procedure. Comorbidities such as extreme age, diabetes, and pulmonary and cardiac illnesses make it more challenging to manage. With the proper evaluation of comorbidities and avoiding long, cumbersome procedures, we can provide patients a fairly good chance of survival.

Continuing cancer surgery through the first six months of the COVID-19 pandemic at an academic university hospital in India: A lower-middle-income country experience.

BACKGROUND: The novel coronavirus pandemic (COVID-19) hinders the treatment of non-COVID illnesses like cancer, which may be pronounced in lower-middle-income countries. METHODS: This retrospective cohort study audited the performance of a tertiary care surgical oncology department at an academic hospital in India during the first six months of the pandemic. Difficulties faced by patients, COVID-19-related incidents (preventable cases of hospital transmission), and modifications in practice were recorded. RESULTS: From April to September 2020, outpatient consultations, inpatient admissions, and chemotherapy unit functioning reduced by 62%, 58%, and 56%, respectively, compared to the same period the previous year. Major surgeries dropped by 31% with a decrease across all sites, but an increase in head and neck cancers (p = .012, absolute difference 8%, 95% confidence interval [CI]: 1.75% - 14.12%). Postoperative complications were similar (p = .593, 95% CI: -2.61% - 4.87%). Inability to keep a surgical appointment was primarily due to apprehension of infection (52%) or arranging finances (49%). Two COVID-19-related incidents resulted in infecting 27 persons. Fifteen instances of possible COVID-19-related mishaps were averted. CONCLUSIONS: We observed a decrease in the operations of the department without any adverse impact in postoperative outcomes. While challenging, treating cancer adequately during COVID-19 can be accomplished by adequate screening and testing, and religiously following the prevention guidelines.

Impact of COVID-19 pandemic on cancer surgery: Patient's perspective.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has impacted cancer care globally. The aim of this study is to analyze the impact of COVID-19 on cancer healthcare from the perspective of patients with cancer. METHODS: A cross-sectional survey was conducted between June 19, 2020, to August 7, 2020, using a questionnaire designed by patients awaiting cancer surgery. We examined the impact of COVID-19 on five domains (financial status, healthcare access, stress, anxiety, and depression) and their relationship with various patient-related variables. Factors likely to determine the influence of COVID-19 on patient care were analyzed. RESULTS: A significant adverse impact was noted in all five domains (p = < 0.05), with the maximal impact felt in the domain of financial status followed by healthcare access. Patients with income levels of INR < 35 K (adjusted odds ratio [AOR] = 1.61, p < 0.05), and 35K- 100 K (AOR = 1.96, p < 0.05), married patients (AOR = 3.30, p < 0.05), and rural patients (AOR = 2.82, p < 0.05) experienced the most adverse COVID-19-related impact. CONCLUSION: Delivering quality cancer care in low to middle-income countries is a challenge even in normal times. During this pandemic, deficiencies in this fragile healthcare delivery system were exacerbated. Identification of vulnerable groups of patients and strategic utilization of available resources becomes even more important during global catastrophes, such as the current COVID-19 pandemic. Further work is required in these avenues to not only address the current pandemic but also any potential future crises.

Searching for answers: Cancer care during the COVID pandemic.

The unprecedented novel coronavirus disease pandemic has wreaked havoc on healthcare systems worldwide and raised myriads of questions. The delivery of cancer care is an essential service that cannot take a backseat, even amid a global pandemic. Oncology involves the disciplines of surgical oncology, radiotherapy, chemotherapy, and palliative care which are all affected, including the possible impact of the pandemic on the mental health of patients and healthcare workers alike. This commentary attempted to review these questions in light of the best available evidence. The delivery of cancer care is generally safe when routine safety precautions are followed, and decisions are based on rational scheduling and logistical prioritisation. The impact on the mental health is profound that needs to be addressed with adequate avenues. Teleoncology is a reasonable alternative, whenever applicable. Evidence-based decision making should be the standard of care, and multidisciplinary management decisions are as indispensable as ever.

Paramedian forehead flap reconstruction for skin tumors involving central subunit of face: An analysis of 37 cases.

INTRODUCTION: Tumors of facial skin are common in upper part of central subunit of face. Defects after resection require a flap, which is pliable, thin, and has a good colour match. Among the various local flaps available paramedian forehead flap is a good option. PATIENTS AND METHODS: Patients reconstructed with paramedian forehead flap during the period from January 2015 to March 2020 were included in the study. Data regarding the demographic, clinical characteristics, and treatment details was recorded, and analyzed for postoperative complications and cosmetic outcomes. RESULTS: Paramedian forehead flap reconstruction was performed in 37 patients who were resected for tumor involving upper central subunit of face. Median age of patients was 57 years. Male to female ratio was 1.4:1. All tumors were resected with a negative margin. Nodal disease was managed by superficial parotidectomy only (4/37), superficial parotidectomy along with supra-omohyoid neck dissection (6/37) and modified neck dissection (1/37). In five patients additional buccal mucosa graft was used to reconstruct conjunctiva. Additional flaps were required in two patients in whom nasolabial and mustarde flaps were used. Partial flap loss occurred in one patient. There was no major flap loss. Surgical site infection developed in only one patient, who had partial flap loss. On subjective assessment, nearly 60% patients described their appearance as good. CONCLUSION: Facial reconstruction in area of dorsum of nose and medial aspect of both eyelids using paramedian forehead flaps is a simple and quick procedure.

Study of tumor transglutaminase 2 expression in gallbladder cancer - Is it a novel predictor of survival?

BACKGROUNDS/AIMS: Transglutaminase 2 (TG2) is known to be an important mediator of inflammation induced carcinogenesis pathway. Chronic inflammation is the most important causative factor in Gallbladder cancer (GBC) carcinogenesis. We analyzed the expression of TG2 in GBC and its role as potential prognostic marker, first of its kind study. METHODS: We analyzed TG2 expression in 100 cases of GBC and 28 cases of non-cancer gallbladder specimen (calculus cholecystitis). We studied TG2 expression in GBC in comparison to control group and evaluated its role as a potential prognostic marker. RESULTS: TG2 score (1-9) was calculated by multiplying percentage cytoplasmic expression (P) with intensity of expression (I) in tumor cells. Positive TG-2 expression was observed in 62% of GBC patients compared to only 21% (n=6) in control group (p=0.001). In curative resection subgroup (n=54), TG2 positive patients showed shorter disease free survival rate (p=0.04) and higher rate of recurrence (p=0.03) compared to TG2 negative patients. TG2 positive expression was observed in 15/16 of patients with recurrent disease. In palliative treatment subgroup, patients with strong TG2 positive expression had poorer disease specific survival (p=0.01) as compared to weakly positive group. On multivariate analysis, lymph node status (p=0.03) and TG2 expression (p=0.037), were found to be significant predictor of recurrence and eventual survival. CONCLUSIONS: Positive TG2 expression was related to higher recurrence rates post curative surgery, shorter disease free and overall survival and ultimately portended poor prognosis. It may be helpful in better prognostication and tailoring therapeutic approach for better management of GBC.