A Randomized Clinical Study to Compare the Perioperative Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block Over Thoracic Epidural in Modified Radical Mastectomy.

Aim This study aims to compare the effectiveness of ultrasound-guided erector spinae block (ESB) with thoracic epidural (TE) in managing postoperative pain among breast cancer (BC) surgery patients. Methods A total of 42 patients were enrolled and randomly divided into two groups, each comprising 21 participants. Primary endpoints assessed included intraoperative fentanyl consumption, postoperative pain scores, and the need for rescue analgesia. Secondary endpoints encompassed intraoperative hemodynamic changes and the incidence of postoperative nausea and vomiting (PONV). Results The study found no significant difference in intraoperative fentanyl requirement (p=0.62) or postoperative pain scores measured using numerical rating scores (NRS) throughout the 48-hour postoperative period. None of the patients in either group required rescue analgesia. Notably, there was a statistically significant difference in postoperative nausea and vomiting at the two-hour mark, favoring the erector spinae block. Both groups exhibited comparable hemodynamic changes during intraoperative monitoring. Conclusions Our investigation concludes that the ESF offers equivalent analgesic efficacy to the thoracic epidural during both surgery and the postoperative period without inducing any significant hemodynamic instability. Considering the lower complication rate associated with paraspinal blocks compared to neuraxial blocks, the ESB presents itself as a promising alternative method for effective pain relief in mastectomy procedures.

Successful Outcome of Metastatic Pancreatoblastoma in an Adolescent: A Case Report and Review of the Literature.

Pancreatoblastoma, an orphan disease, is the most common malignant epithelial neoplasm of the pancreas in children. With vague clinical features, diagnosis is made by radiological suggestions and histopathology. The presence of metastatic disease and inoperable/incomplete excision remains the poor prognostic markers. We present a rare instance of an adolescent who has survived metastatic pancreatoblastoma after neoadjuvant chemoreduction/complete surgical excision.

Concurrent Taxol-Based Doublet Chemotherapy as an Alternative for Intracavitary Brachytherapy Boost in Locally Advanced Carcinoma Cervix- Retrospective Analysis From a Tertiary Care Center.

Objective In light of the dogma that brachytherapy is irreplaceable for the successful treatment of cervical cancer, and the limited availability of brachytherapy facilities in developing countries, we sought to evaluate the toxicity and efficacy of taxol- and platinum-based doublet chemotherapy delivered concurrently with external beam radiotherapy (EBRT) in locally advanced cervical cancer as an alternative to brachytherapy, which is mandated as the standard of care according to current guidelines. Methods The records from our institution were reviewed to identify patients who underwent chemoradiation with two doses of tri-weekly docetaxel (80mg/m2) and carboplatin (AUC 5) concurrent with EBRT between January 2017 and 2019 for locally advanced cervical carcinoma. Here, 48 cases were analysed, with a median follow-up period of two years. Results The two groups were homogenously matched, and the patients who received EBRT boost and brachytherapy boost achieved complete pathological response rates of 68% and 83%, respectively (p=0.243). The odds ratio was 0.45 (95% confidence interval, 0.09-2.08), indicative of non-significance and non-inferiority based on the analysis using the chi-squared test (with Pearson's correlation) and Student's t-test. The disease-free survival durations calculated using Kaplan-Meier estimates were 22 and 24 months, two-year disease-free survival rates were 83% and 91.3%, and two-year overall survival (OS) were 85.6% and 94% for the EBRT boost and brachytherapy boost groups, respectively (p=0.657). Conclusion In this retrospective analysis, we concluded that EBRT boost was non-inferior to brachytherapy boost and could be considered as a reasonable alternative in locally advanced cervical cancer when used concurrently with more dose-intense chemotherapy.

Endometriosis of para-aortic node masquerading a malignancy: a rare occurrence.

Endometriosis is a benign estrogen-dependent disorder affecting women in their reproductive age group. Endometriosis means 'abnormal growth of endometrial glands' outside the uterus. Multiple theories on aetiopathogenesis of endometriosis have been postulated, Halban's theory on 'Benign Metastasis' which proposed the presence of endometriotic cells in lymphatic vessels and lymph nodes provides the basis of this case report. Here, we report a case of 26-year-old nulliparous woman who presented with grossly elevated CA 125 with endometriosis in her para-aortic nodes mimicking as ovarian cancer.

Chest wall resection in locally advanced or recurrent breast cancer - series of three cases.

BACKGROUND: The usefulness of chest wall resection in breast cancer is poorly defined as extensive surgical resection is seen inappropriate, as it is regarded as harbinger of systemic disease. We report our experience of chest wall resection in recurrent or locally advanced breast cancers Case Presentation: We reviewed our institute records for chest wall resection in locally advanced or locally recurrent breast cancers from 2016 - 2018. There were 3 cases of chest wall resection for carcinoma breast. 1 for recurrent breast cancer and 2 for locally advanced breast cancer after neoadjuvant chemotherapy. Preoperative symptoms were ulceration in recurrent tumor, pain and mass in other. One patient needed Lattismus dorsi (LD) myocutaneous flap and one required a free flap. One underwent LD muscle flap. Mean postop stay were 8 days. One patient required redo flap surgery for partial flap necrosis Conclusions: Full thickness chest wall resection is relatively safe procedure with acceptable morbidity and can be considered in carefully selected patients Key Words: Breast carcinoma-Chest wall recurrence- Chest wall resection-chest wall reconstruction.

Thoracoscopic (hybrid) complex chest wall resection in pediatric Ewing sarcoma.

Askin tumor (a Ewing sarcoma variant) is the most common tumor of the chest wall in the pediatric age group. Multimodal treatment is required, with complete resection being the cornerstone of effective management. We describe the case of a 13-year boy with a left paraspinal Ewing sarcoma with intraspinal extension and spinal cord compression with neurological weakness. He underwent complex surgical resection using thoracoscopic resection of multiple ribs along with vertebral resection and reconstruction, after neoadjuvant therapy.

Solitary recurrence at intercostal drain site in oesophageal adenocarcinoma.

56 year old gentleman was evaluated for dysphagia and diagnosed with oesophageal adenocarcinoma and had undergone Transhiatal Oesophagectomy elsewhere, pT3N0, but had defaulted adjuvant treatment. He presented 15 months later to us with nodule at left intercostal drain (ICD) drain site. Positron Emission Tomography (PET) scan showed it to be single site metastasis and he underwent wide excision, followed by six cycles of chemotherapy. He is symptom free and on regular follow up for a period of ten months. Oesophageal cancer although with poor prognosis can be considered for metastatectomy after considering the disease free interval, site of recurrence and histological factors in carefully selected patient.

VATS Right Upper Lobe Anterior Segmentectomy in Post Left Pneumonectomy: Technique.

Lung resection following pneumonectomy for recurrent lung cancer is a challenging scenario. Peri-operative airway management and choice of surgical procedure are issues to be addressed by both the anesthesiologists and thoracic surgeons. We hereby report a case of anterior segmentectomy of the right upper for recurrent lung cancer, in a patient who had previously underwent pneumonectomy for primary lung cancer one year earlier. A modified conventional tracheal intubation and unique surgical techniques were applied for video-assisted thoracoscopic surgery (VATS) anterior segmentectomy of the right upper lobe in a patient with a notable mediastinal shift (following contralateral pneumonectomy), resulting in a good recovery and clinical outcome. The clinical experience is summarized in detail in this article.

Pancreatic metastasis of dermatofibrosarcoma protuberans: a rare case.

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue malignancy which is locally aggressive, slow growing. It has a very low metastatic potential and has high risk of local recurrence. We report a 65-year-old man with recurrent DFSP of thigh with pancreatic metastasis. Apart from our patient, only four other cases of pancreatic metastasis of DFSP have been reported. Our patient had a solitary metastasis to pancreas and was treated with distal pancreaticosplenectomy. Outcome of the patient was good. We present this case report to emphasise that resection may be considered for solitary metastasis of DFSP and can be managed successfully.

Prognostic Factors and Survival Outcomes of Surgical Resection of Huge Hepatocellular Carcinomas.

INTRODUCTION: The aim of the study was to analyze the various prognostic factors that influence survival and clinical outcomes in patients undergoing liver resection for huge hepatocellular carcinomas. MATERIALS AND METHODS: The records of patients who underwent curative surgery between 1991 and 2011 for huge hepatocellular carcinoma were analyzed. Various prognostic factors that influenced the survival were studied. The patients were followed up till November 2016. RESULTS: The number of patients who underwent liver resection with huge hepatocellular carcinoma during the study period was 17; this included 14 males and 3 females. The median age of the study population was 52 years. The median serum AFP in the study population was 132.3 ng/ml (range 2 to 187,000 ng/ml). 41.2% of the patients were hepatitis B positive. The overall morbidity was 6%. The mortality rate was nil. The mean size of the resected specimen was 13.9 cm ± 3.6 cm. The overall recurrence rate was 76.5%. The local recurrence rate was 29.4%. The median time to recurrence was 8 months. The 5-year disease-free survival and overall survival of the study group were 26% and 32%, respectively. The factors that predicted an adverse survival outcome after the log-rank test for univariate analysis using life-table method were presence of lymphovascular invasion (p = 0.047), age ≤ 55 years (p = 0.021), and raised serum AFP (p = 0.041). CONCLUSION: The factors that predict an adverse outcome after surgery in patients with huge hepatocellular carcinomas were the presence of lymphovascular invasion, raised serum AFP, and age ≤ 55 years.

Role of Pelvic Lymphadenectomy in Intermediate-Risk Endometrial Cancer and Predictors of Nodal Positivity in Indian Patients.

One of the most intense controversies in endometrial cancer revolves around the need for lymphadenectomy at the time staging. The study carried out to analyze the role of staging with pelvic lymphadenectomy in intermediate-risk stage I endometrial cancer-stage IA grade III and stage IB grades I and II. Review analysis of all the patients with stage I carcinoma endometrium intermediate risk treated at our institution between January 2006 and December 2014. All demographic data, tumor factors, adjuvant treatment, follow-up, and recurrence were recorded. Sixty-five were in intermediate-risk group, of which 21 were in low intermediate- and 44 in high intermediate-risk group, with 4 patients with positive pelvic node in each group. In patients with low intermediate-risk stage IA, grade III tumors, the nodal involvement was substantial even when the myometrial invasion was less than 50%. All grade 1 tumors did not have pelvic nodal metastasis. Overall percentage of pelvic nodal metastasis in our review of intermediate-risk carcinoma endometrium was 12%, with 19% in stage IA, grade III tumors, and 9% with stage IB, grade I and II tumors. A systematic lymphadenectomy should be done in patients with endometrial cancer who are at intermediate to high risk of lymph node metastases. The grade III histology is more likely to predict for nodal metastasis more than depth of myometrial invasion. It is recommended to stratify patients into risk groups to formulate guidelines for therapeutic lymphadenectomy.

Utility of Preoperative Staging of Ipsilateral Axilla with Ultrasound and Guided Needle Aspiration in Early-Stage Breast Cancer-Current Indian Scenario.

Clinical assessment of the axilla, especially in early-stage breast cancer, can have a high degree of inaccuracy with over-staging curtailing the use of sentinel node biopsy. Imaging of axilla, using ultrasound ± guided fine needle aspiration cytology (FNAC) can help in better staging. In this study, we aim to compare physical examination and ultrasound of axilla and FNAC and assess their accuracy in preoperative staging of axilla. This was a prospective observational study. Patients with biopsy-proven invasive early-stage breast carcinoma, consenting to be part of the study, underwent ultrasound (US) of ipsilateral axilla with guided FNAC, when indicated and underwent surgery which included complete axillary dissection. Postoperative histopathology was compared to preoperative US and guided cytology (if done), to correlate the latter's efficacy in detecting positive axillary nodes. Clinically, 96% of patients had palpable axillary nodes, though of doubtful significance. On US axilla, 62% had suspicious nodes (guided FNAC was performed). Sensitivity and specificity of US axilla was 90.9% and 60.7%, with sensitivity reaching 100% in patients with > 1 node positive, while that of US + FNAC was 85.7 and 100% respectively. Although all US nodal parameters studied showed positive correlation with final nodal pathology (p < 0.005), loss of fatty hilum was the best predictor of metastatic nodal disease. Preoperative ultrasound of ipsilateral axilla ± FNAC helps in better preoperative staging of axilla. Its routine use can help reduce the false positivity of clinical examination and help in avoiding unnecessary axillary dissection and also in better selection of patients for sentinel node biopsy.

Surgical Resection for Hepatoblastoma-Updated Survival Outcomes.

BACKGROUND: Hepatoblastoma is the most common liver malignancy in the pediatric age group. The management of hepatoblastoma involves multidisciplinary approach. METHODS: Patients with hepatoblastoma who underwent liver resection between 2000 and 2013 were analyzed and survival outcomes were studied. RESULTS: The crude incidence rate of hepatoblastoma at the Madras Metropolitan Tumor Registry (MMTR) is 0.4/1,00,000 population per year. Twelve patients underwent liver resection for hepatoblastoma during the study period; this included eight males and four females. The median age at presentation was 1.75 years (Range 5 months to 3 years). The median serum AFP in the study population was 20,000 ng/ml (Range 4.5 to 1,40,000 ng/ml). Three patients had stage I, one patient had stage II, and eight patients had stage III disease as per the PRETEXT staging system. Two patients were categorized as high risk and ten patients were categorized as standard risk. Seven of these patients received two to four cycles of neoadjuvant chemotherapy (PLADO regimen), and one patient received neoadjuvant radiation up to 84 Gy. Major liver resection was performed in nine patients. Nine patients received adjuvant chemotherapy. The most common histological subtype was embryonal type. Microscopic margin was positive in three cases. One patient recurred 7 months after surgery and the site of failure was the lung. The 5-year overall survival of the case series was 91%. The median survival was 120 months. CONCLUSION: Liver resections can be safely performed in pediatric populations after neoadjuvant treatment. Patients undergoing surgery had good disease control and long-term survival.

Role of 68Ga-DOTATOC PET/CT in initial evaluation of patients with suspected bronchopulmonary carcinoid.

PURPOSE: The objective of this study was to evaluate the role of (68)Ga-DOTATOC positron emission tomography (PET)/CT scan in patients with suspected pulmonary carcinoid tumour and to compare its results with (18)F-fluorodeoxyglucose (FDG) PET/CT scan. METHODS: In this prospective study, 32 patients (age 34.22 ± 12.03 years; 53.1 % female) with clinical suspicion of bronchopulmonary carcinoid were evaluated with (68)Ga-DOTATOC PET/CT and (18)F-FDG PET/CT. The two imaging modalities were compared, considering the tissue diagnosis as the reference standard. RESULTS: Based on the reference standard 26 cases were carcinoid tumours [21 typical carcinoids (TC) and 5 atypical carcinoids (AC)] and 6 cases were non-carcinoid tumours. The sensitivity, specificity and accuracy of (68)Ga-DOTATOC PET/CT in the diagnosis of pulmonary carcinoid tumour were 96.15, 100 and 96.87 % respectively, whereas those of (18)F-FDG PET/CT were 78.26, 11.1 and 59.37 % respectively. The maximum standardised uptake value (SUV max) of TC on (68)Ga-DOTATOC PET/CT scan ranged from 3.58 to 55, while that of AC ranged from 1.1 to 32.5. (18)F-FDG PET/CT was true-positive in all cases of AC and false-negative in eight cases of TC (sensitivity for TC 61.9 % and for AC 100 %). CONCLUSION: (68)Ga-DOTATOC PET/CT is a useful imaging investigation for the evaluation of pulmonary carcinoids. (18)F-FDG PET/CT scan suffers from low sensitivity and specificity in differentiating the pulmonary carcinoids from other tumours.

68Ga-DOTATOC PET-CT in the localization of source of ectopic ACTH in patients with ectopic ACTH-dependent Cushing's syndrome.

Localization of the source of adrenocorticotrophic hormone (ACTH) in ectopic ACTH-induced Cushing's syndrome is of paramount importance as definitive management mainly involves surgical resection of tumor. Many of these are occult, not identified by conventional structural imaging. Accurate localization and assessment of their functional status has become feasible with the use positron emission tomography-computerized tomography using (68)Ga-DOTATOC (1,4,7,10-tetraazacy-clododecane-NI,NII,NIII,NIIII-tetraacetic acid(D)-Phe1-thy3-octreotide), aiding in proper planning for their definitive management.

Evaluation of the role of [18F]FDG-PET/CT and [68Ga]DOTATOC-PET/CT in differentiating typical and atypical pulmonary carcinoids.

Pulmonary carcinoids are histologically classified into typical and atypical. It is important to identify these preoperatively for treatment planning and prognosis. Structural imaging cannot conclusively differentiate between them. The aim of this study was to assess the possibility of differentiating the 2 variants using [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) and [68Ga]1,4,7,10-tetraazacyclododecane-N(I-IIII)-tetraacetic acid-(D)-Phe1-Thy3-octreotide (DOTATOC)-PET/CT. The imaging results of 20 patients with pulmonary carcinoids (13 typical, 7 atypical) on [18F]FDG-PET/CT and [68Ga]DOTATOC-PET/CT were assessed retrospectively. Six typical carcinoids failed to reveal significant uptake on [18F]FDG-PET/CT. All the atypical carcinoids revealed significant uptake on the [18F]FDG-PET/CT that was higher than that in typical carcinoids (standardized uptake value (SUV)max, 2.9-8.4, P = 0.001). The SUVmax in typical carcinoids on [68Ga]DOTATOC-PET/CT was significantly higher (SUVmax, 8.8-66) compared with atypical carcinoids (SUVmax, 1.1-18.5, P = 0.002). Ratios of SUVmax on [68Ga]DOTATOC-PET/CT to that on [18F]FDG-PET/CT were significantly higher (P < 0.001) in typical carcinoids compared with atypical carcinoids. The different uptake patterns on [18F]FDG and [68Ga]DOTATOC-PET/CT. and the ratio of SUVmax may be helpful in differentiating between typical and atypical carcinoids.

Role of (68)Ga-DOTATOC PET/CT in the evaluation of primary pulmonary carcinoids.

BACKGROUND/AIMS: Although carcinoid tumors usually have good prognosis, early and specific diagnosis is important. Computed tomography and magnetic resonance imaging do not provide findings that are specific for carcinoids, and somatostatin receptor scintigraphy suffers from low spatial resolution. 18-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has limited sensitivity for carcinoids due to low uptake of the marker. A PET/CT system that uses the somatostatin receptor-based PET tracer 1,4,7,10-tetraazacyclododecane-N(I),N(II),N(III),N(IIII)-tetraacetic acid (D)-Phe(1)-thy(3)-octreotide ((68)Ga-DOTATOC) has also been used in the evaluation of carcinoids, although information regarding its use for the detection of primary pulmonary carcinoids is limited. Thus, we investigated the value of (68)Ga-DOTATOC PET/CT for the diagnosis of primary pulmonary carcinoid tumors. METHODS: This was a retrospective analysis of patients with primary pulmonary tumors who underwent (68)Ga-DOTATOC PET/CT. All the patients had a histopathologic diagnosis of carcinoid. The rate of detection of primary pulmonary carcinoid tumors using (68)Ga-DOTATOC PET/CT was assessed. RESULTS: Twenty patients were diagnosed as having carcinoid, and 19 tumors showed significant uptake on (68)Ga-DOTATOC (detection rate, 95%). The maximal standardized uptake value (SUV(max)) ranged from 1.1 to 66, with a median value of 21.6. In one patient, (68)Ga-DOTATOC PET/CT revealed additional lesions. CONCLUSIONS: Our results demonstrate that (68)Ga-DOTATOC PET/CT is useful in the evaluation of primary pulmonary carcinoids and should be included in the diagnostic work-up of these patients.