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1.
Dis Colon Rectum ; 2021 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-34907988

RESUMO

BACKGROUND: Short course radiotherapy followed by chemotherapy has not been widely evaluated as an alternative to traditional long course chemoradiotherapy in locally advanced rectal cancer. OBJECTIVE: Study comparing oncological and short term outcomes between short course radiotherapy + chemotherapy and long course chemoradiotherapy in locally advanced rectal cancer. DESIGN: This is a retrospective propensity matched study. SETTINGS: The study was conducted at a colorectal department in a tertiary care oncology center in India. PATIENTS: There were 173 patients. Group A had 47 and group B had 126 patients. A 1:2.7 matching was done for age, sex, distance of tumor from anal verge, sphincter preservation surgeries, MRI based pre-treatment T stage and circumferential resection margin (CRM). INTERVENTIONS: Short course radiotherapy + chemotherapy (group A) and long course chemoradiotherapy (Group B) in LARC in locally advanced rectal cancer. MAIN OUTCOME MEASURES: The primary measures were pathological CRM positivity, downstaging, tumor regression grade, postoperative complications. RESULTS: There were 52% patients had positive circumferential resection margin on MRI, 57% low rectal tumors, 20% T4 tumors. Distribution of rectal surgeries was similar between the 2 groups. pT downstaging and tumor regression scores were significantly better in group B (p= 0.028 and 0.026 respectively). Pathological circumferential resection margin, distal resection margin and nodal yield were similar. On Multivariate analysis - pretreatment N status was the only independent predictive factors for pCRM status. Grade 3-4 Clavien-Dindo complications, anastomotic leak rates and hospital stay were similar between the two groups. LIMITATION: This was a retrospective study. Although propensity matching was performed, selection bias cannot be eliminated completely as seen in the difference in the surgical approaches between the two groups. CONCLUSIONS: In a cohort containing significant portion of MRI circumferential resection margin positive low rectal cancers, short course radiotherapy +chemotherapy followed by delayed surgery resulted in lower T downstaging and lower tumor regression scores compared to long course chemoradiotherapy. But pathological circumferential margin status, distal resection margin, nodal yield and perioperative morbidity were similar between the two groups. This suggests that short course radiotherapy +chemotherapy could be a viable alternative to long course chemoradiotherapy in locally advanced rectal cancers. See Video Abstract at http://links.lww.com/DCR/B855.

2.
Indian J Radiol Imaging ; 31(3): 560-565, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34790298

RESUMO

Background Presence of extramural venous invasion (EMVI) is a poor prognostic factor for rectal cancer as per literature. However, India-specific data are lacking. Aim The aim of the study is to determine the prognostic significance of EMVI in locally advanced rectal cancer on baseline MRI. Materials and Methods We retrospectively reviewed 117 MRIs of operable non-metastatic locally advanced rectal cancers in a tertiary cancer institute. Three dedicated oncoradiologists determined presence or absence of EMVI, and its length and thickness, in consensus. These patients were treated as per standard institutional protocols and followed up for a median period of 37 months (range: 2-71 months). Kaplan-Meier curves (95% CI) were used to determine disease-free survival (DFS), distant-metastases free survival (DMFS), and overall survival (OS). Univariate analysis was performed by comparing groups with log-rank test. Results EMVI positive cases were 34/114 (29%). More EMVI-positive cases developed distant metastasis compared with EMVI-negative cases (14/34-41% vs. 22/83-26%). The difference, however, was not statistically significant ( p = 0.146). After excluding signet-ring cell cancers ( n = 14), EMVI showed significant correlation with DMFS ( p = 0.046), but not with DFS or OS. The median thickness and length of EMVI was 6 and 14 mm, respectively in patients who developed distant metastasis, as compared with 5 and 11 mm in those who did not, although this difference was not statistically significant. Conclusion EMVI is a predictor of distant metastasis in locally advanced non-metastatic, non-signet ring cell rectal cancers. EMVI can be considered another high-risk feature to predict distant metastasis.

3.
Front Oncol ; 11: 710585, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34568037

RESUMO

Background: Treatment of malignant melanoma has undergone a paradigm shift with the advent of immune checkpoint inhibitors (ICI) and targeted therapies. However, access to ICI is limited in low-middle income countries (LMICs). Patients and Methods: Histologically confirmed malignant melanoma cases registered from 2013 to 2019 were analysed for pattern of care, safety, and efficacy of systemic therapies (ST). Results: There were 659 patients with a median age of 53 (range 44-63) years; 58.9% were males; 55.2% were mucosal melanomas. Most common primary sites were extremities (36.6%) and anorectum (31.4%). Nearly 10.8% of the metastatic cohort were BRAF mutated. Among 368 non-metastatic patients (172 prior treated, 185 de novo, and 11 unresectable), with a median follow-up of 26 months (0-83 months), median EFS and OS were 29.5 (95% CI: 22-40) and 33.3 (95% CI: 29.5-41.2) months, respectively. In the metastatic cohort, with a median follow up of 24 (0-85) months, the median EFS for BSC was 3.1 (95% CI 1.9-4.8) months versus 3.98 (95% CI 3.2-4.7) months with any ST (HR: 0.69, 95% CI: 0.52-0.92; P = 0.011). The median OS was 3.9 (95% CI 3.3-6.4) months for BSC alone versus 12.0 (95% CI 10.5-15.1) months in any ST (HR: 0.38, 95% CI: 0.28-0.50; P < 0.001). The disease control rate was 51.55%. Commonest grade 3-4 toxicity was anemia with chemotherapy (9.5%) and ICI (8.8%). In multivariate analysis, any ST received had a better prognostic impact in the metastatic cohort. Conclusions: Large real-world data reflects the treatment patterns adopted in LMIC for melanomas and poor access to expensive, standard of care therapies. Other systemic therapies provide meaningful clinical benefit and are worth exploring especially when the standard therapies are challenging to administer.

4.
ANZ J Surg ; 91(11): 2475-2481, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34427027

RESUMO

BACKGROUND: The safety of inter-sphincteric resection (ISR) for low rectal cancer with adverse histologic subtypes has been incompletely studied. The present study aims at determining the risk of local recurrence with this procedure in poorly differentiated and signet ring cell (PDSR) adenocarcinoma. METHODS: Retrospective analysis from a single tertiary cancer centre of non-metastatic primary rectal cancer <6 cm from the anal verge that underwent ISR. Competing risk analysis and sub-distribution hazard ratios for local recurrence free survivals were calculated to determine factors that influenced local recurrence with the competing risk of death from any cause to overcome the exceeding risk of distant metastasis associated with adverse histologic types. RESULTS: One hundred forty-two patients underwent ISR and 22.6% has PDSR histology. At a median follow up of 61 months, 15.6% of the PDSR cohort developed local recurrence (five patients) compared to 11.7% in the non-PDSR group. PDSR histology influenced overall and disease free survival but not local recurrence on cox regression. On competing risk analysis, only ypT stage ≥3 predicted worse local recurrence free survival and not histology. CONCLUSIONS: The presence of PDSR histology did not increase the risk of local recurrence after ISR in this retrospective competing risk analysis.


Assuntos
Recidiva Local de Neoplasia , Neoplasias Retais , Canal Anal , Humanos , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Retais/cirurgia , Reto , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
5.
Indian J Surg Oncol ; 12(2): 241-245, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34295065

RESUMO

An ideal method of perineal closure after resection for low rectal cancer surgery is a topic of debate. Morbidity associated with primary perineal closure due to wound break down delays recovery from surgery and adjuvant treatment with poor oncological outcome at the end. Herewith, we present our experience with V-Y gluteal advancement fasciocutaneous flap done for 131 patients for reconstruction of perineal and pelvic defect. With our experience, this is a safe and simple method with an acceptable complication rate that can be practiced by colorectal surgeons, even in the absence of a dedicated plastic surgery team.

6.
Indian J Crit Care Med ; 25(5): 590-593, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34177182

RESUMO

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality for peritoneal surface malignancies. A variety of metabolic derangements have been reported in the perioperative period in these patients, most of which are a result of the complex interaction of peritoneal denudation, chemotherapy bath, and fluid imbalance. We report three cases of hyperammonemia-related neurological dysfunction seen in HIPEC patients. To the best of our knowledge, this is the first report of this presentation. Timely recognition of this condition needs a high degree of suspicion, and unless aggressively treated, is likely to be associated with poor outcome. How to cite this article: Sharma V, Solanki SL, Saklani AP. Hyperammonemia after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Report of Three Cases with Unusual Presentation. Indian J Crit Care Med 2021;25(5):590-593.

10.
Pleura Peritoneum ; 5(3): 20200126, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33364341

RESUMO

Objectives: Cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC) for peritoneal malignancies are complex surgeries marked with hemodynamic perturbations, temperature fluctuations, blood loss and metabolic disturbances in the intra-operative and post-operative period. In this report, we highlighted perioperative factors which may have led to cardiac arrest in immediate postoperative period and subsequent successful resuscitation in two patients with high volume peritoneal cancers who underwent CRS-HIPEC. Case presentation: Both patients had a similar clinical course, characterized by massive blood and fluid loss, metabolic derangement, hemodynamic instability, long duration of surgery, post HIPEC rebound hypothermia and hypokalemia which need to be anticipated. Conclusions: We reviewed the literature related to postoperative hypothermia and other major complications after CRS-HIPEC and correlated the available literature with our findings.

11.
Ann Surg ; 272(3): e249-e252, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32520743

RESUMO

BACKGROUND: Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots. METHODS: A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020. FINDINGS: Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV - VI).Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in <60 years (P = 0.169). The median hospital stay was 1 to 9 days across specialties.Postoperatively, 26 patients were tested for COVID 19 and 6 tested positive. They all had higher grade surgeries but none required escalated or intensive care treatment related to COVID infection. INTERPRETATION: A combination of scientific and administrative rationale contributed to favorable outcomes after major elective cancer surgeries. These results support the continuation of elective major cancer surgery in regions with Covid 19 trends similar to India.


Assuntos
COVID-19/epidemiologia , Procedimentos Cirúrgicos Eletivos , Neoplasias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Neoplasias/mortalidade , Neoplasias/patologia , Avaliação de Resultados em Cuidados de Saúde , Seleção de Pacientes
12.
Indian J Anaesth ; 63(12): 972-987, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31879421

RESUMO

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

13.
Indian J Radiol Imaging ; 29(2): 133-140, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31367084

RESUMO

Gastrointestinal stromal tumor (GIST) are the most common non epithelial tumor of the gastrointestinal (GI) tract. They arise from interstitial cells of Cajal present in the myenteric plexus. They can also arise outside the GI tract from mesentery, retro peritoneum and omentum. With the advent of new targeted molecular therapy c- tyrosine kinase inhibitor (Imatinib), it has become important to differentiate between response and pseudo-progression of the disease as response evaluation criteria for GIST are different from Response Evaluation Criteria in Solid Tumors (RECIST). Purpose of this pictorial essay is to enumerate the characteristic CT features of GIST, and discuss atypical features and response evaluation criteria.

14.
Indian J Anaesth ; 63(2): 134-137, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30814751

RESUMO

Peritoneal carcinomatosis is intraperitoneal spread of gastrointestinal and gynaecological cancers. Cytoreductive surgeries and hyperthermic intraperitoneal chemotherapy offers survival benefits in these cases. Spread of peritoneal carcinomatosis to thorax pose challenges to surgeon and anaesthesiologist. Haemodynamic, temperature and coagulopathy monitoring as well as intraoperative airway pressure, pre- and postoperative pulmonary function test monitoring is required in these cases where diaphragm excision is done and intraoperative intra peritoneal as well as pleural chemotherapy is given. We are reporting a case of pseudomyxoma peritonei involving the abdomen and left side of pleura and lung, posted for cytoreductive surgery and hyperthemic chemotherapy to abdomen and thorax, i.e., hyperthemic intraoperative thoraco-abdominal chemotherapy.

15.
Indian J Surg Oncol ; 9(4): 452-455, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30538371

RESUMO

Close surveillance of colorectal cancer (CRC) patients is helpful as early detection of resectable metastasis has a survival benefit. Ultrasonography (USG) is a frequently used modality to detect liver recurrence, although international guidelines do not include it. To evaluate the potential added role of USG in early detection of CRC recurrence. We performed a retrospective analysis of 230 patients of colorectal cancer treated at our institute in 2013-2014 who underwent abdominal USG for surveillance. 77/230 (33%) developed recurrence, with liver being the second most common site (22/230). 5/230 (2%) patients had recurrent disease first detected on USG, four of which also had raised serum CEA (carcinoembryonic antigen) levels. There were three false positive and four false-negative cases on USG. There was no added advantage of USG for early detection of CRC recurrence.

16.
Indian J Anaesth ; 62(3): 225-228, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29643558

RESUMO

Pressurised intraperitoneal aerosolised chemotherapy (PIPAC) is a new, mostly supportive approach to help patients with advanced peritoneal metastasis to increase the lifespan. It carries occupational hazards to health-care workers and especially anaesthesiologist during the procedure. The aerosolised chemotherapy can also cause chemical peritonitis and organ dysfunction in the perioperative period. In this case report, we present the report of two cases and discuss the perioperative concerns and management related to PIPAC.

17.
Indian J Surg Oncol ; 8(4): 474-478, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29203976

RESUMO

The study aims to compare open intersphincteric resection (OISR) with laparoscopic intersphincteric resection (LISR) in terms of short-term oncological and clinical outcomes. This is a retrospective review of a prospectively maintained database including all the patients of rectal cancer who underwent intersphincteric resection (ISR) at Tata Memorial Centre between 1st July 2013 and 30th November 2015. Short-term oncological parameters evaluated included circumferential resection margin involvement (CRM), distal resection margin involvement, and number of nodes harvested. Perioperative outcomes included blood loss, length of hospital stay and 30-day postoperative morbidity and mortality. Chi-square test was used to compare the results between the two groups. Thirty nine cases of OISR and 34 cases of LISR were included in the study. Median BMI was higher in LISR group; otherwise, the two groups were comparable in all aspects. There were no conversions in LISR group. CRM involvement was seen in four patients (10%) in the conventional group compared to none in the LISR group. Median hospital stay was comparable between the two groups. Laparoscopic ISR is safe and can be performed with low conversion rate in selected group of patients.

18.
Indian J Surg Oncol ; 8(4): 491-498, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29203979

RESUMO

This study aims to compare patient, tumor, treatment-related factors and survival between young (<45 years) and old (>45 years) Indian colorectal cancer (CRC) patients. Total 778 patients of CRC were registered at tertiary cancer center in India between 1 August 2013 and 31 July 2014. Patients were followed up for median period of 27.73 months. Data regarding patient, tumor, treatment and survival-related factors were collected. Patients were divided in young (≤45 years) and old (>45 years) age groups. Statistical analysis was done with SPSS software version 23. Young age group patients presented more commonly with poor histology, node-positive disease, and rectal site. Younger age group patients received multiple lines of neoadjuvant treatment. There was no significant overall survival difference in both groups of patients. On stratified stage-wise analysis, no significant overall survival (OS) difference was found between two groups (young vs old-1- and 3-year OS: 85.2 and 61.5% vs 81.5 and 64.5%, respectively; P = 0.881). On univariate analysis, gender, performance status, site, stage, differentiation, TRG, CRM status, signet ring type, and CEA level were significant prognostic factors. In disease-free survival (DFS) analysis, it is found that there is statistically significant difference in DFS (young vs old: 1 and 3 years; 77.6 and 62.8% vs 85.8 and 74.1%, respectively; P value, 0.02), but when OS was analyzed for same group of patient, there was no statistical difference (P = 0.302). This study confirms the high incidence rates of CRC in young Indian patients. There is no OS difference between two age groups. In operated group of patients, there is higher DFS in older patients but no OS advantage at 3 years follow-up. Further long-term follow-up is required to see any OS difference.

19.
Indian J Surg Oncol ; 8(4): 519-526, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29203984

RESUMO

The purpose of this study is to evaluate the patterns of treatment and factors affecting outcomes in ovarian metastases of colorectal origins treated at our institution and to assess the response of ovarian metastases to chemotherapy. Survival in R0 and R+ resections and patients receiving only chemotherapy is also analyzed. This is a retrospective study of 25 patients registered between January 2012 and December 2015. Patient's age, disease status, mode of presentation, disease spread, mode of treatment, response to chemotherapy, completeness of resection, histology, and outcomes were considered as variables for analysis. There were 21 synchronous presentations and 4 metachronous presentations. In synchronous presentations, only 2 had extra-abdominal disease. Of these patients, 15 underwent surgeries of various extents. The remaining 6 patients were treated with chemotherarpy initially. Only one of them could come up to surgery later. In R0 resections, disease recurred between 1 and 9 months (median 3.5 months). The recurrence was in peritoneum and ovaries. In operated cases, 12 of 15 patients received chemotherapy and 9 patients progressed on first line chemotherapy. In all 4 metachronous patients, the disease was in the peritoneum. No one underwent surgery for the recurrence due to the extensive nature of the disease. All received chemotherapy. Sixty-six percent ovarian metastases showed progression on chemotherapy. There was no significant difference in the median survival between patients treated with surgery plus chemotherapy (23 months) vs. those treated with chemotherapy alone (28 months). Age and presence of disease at other sites did not affect the outcomes. Non-signet ring cell histologies showed better outcomes compared to signet ring cell histology (p = 0.02). Synchronous presentation, R0 resections, and responsive disease showed better survival, however it was clinically not significant. Treatment of ovarian metastases of colorectal origins is varied but has consistently poor outcome. Non-signet histology was the only prognostic factor which showed better outcome. Survival was not different between patients treated with surgery+chemotherapy and chemotherapy alone but majority of ovarian metastases progressed on chemotherapy. Considering the poor response to chemotherapy and peritoneum being the most common site of disease, both in primary and recurrent setting, R0 resection should always be attempted after selecting the correct patients using PET scan, laparoscopy and standard exploratory protocols. Treatment should be tailored upon patient's status and disease burden with an aim to do complete cytoreduction whenever possible. CRS+HIPEC (cytoreductive surgery + hyperthermic intraperitoneal chemotherapy) can be considered on case to case basis as even R0 resections tend to recur.

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