Challenges of cytoreduction in porta hepatis in surgery for advanced ovarian cancer.

Introduction: Advanced ovarian cancer often necessitates aggressive surgical intervention, including cytoreduction of the porta hepatis, which poses significant challenges due to the intricate anatomical structures involved. This surgical video aims to illustrate these challenges and demonstrate effective techniques for clearance of critical structures such as the portal vein (PV), common bile duct (CBD), accessory left hepatic artery (Acc. LHA), obliterated umbilical vein (OUV), inferior vena cava (IVC), and foramen of Winslow. Methods: The surgical procedure depicted in the video involved meticulous dissection and identification of anatomical landmarks to access the porta hepatis. Techniques for safe clearance of the PV, CBD, Acc. LHA, OUV, IVC, and foramen of Winslow were employed and are highlighted in detail. Emphasis was placed on preserving vascular integrity and minimizing intraoperative complications. Conclusions: The video demonstrates the complexities associated with cytoreduction of the porta hepatis in advanced ovarian cancer surgery and offers insights into overcoming these challenges. By utilizing precise surgical techniques and careful anatomical consideration, successful clearance of critical structures can be achieved, thereby optimizing patient outcomes and minimizing postoperative complications. This educational resource provides valuable guidance for surgeons encountering similar challenges in the management of advanced ovarian cancer.

Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis.

Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.

Outcomes of Laparoscopic Optimal Interval Cytoreduction Surgery (LOICS) in Patients with Advanced Ovarian Cancers Having Low Burden Disease.

Laparoscopy has been increasingly utilised for cytoreduction surgery in patients with early ovarian cancers. The present study tries to assess the feasibility of laparoscopic interval cytoreduction surgery (LOICS) in patients with advanced ovarian cancer (AOC) having low burden residual disease. A retrospective study of was done of AOC's who underwent LOICS between 2010 and 2014. Epithelial ovarian cancer patients who underwent interval cytoreduction surgery were included and analysed for short-term and long-term outcomes. In all, 36 patients with stage III ovarian cancers were included in the analysis. Twenty-two (61.1%) were grade 3 and 14 (38.8%) were grade 2, and no patient had grade 1 tumour. Stage wise majority were stage IIIC (94.4%) followed by 2 (5.5%) in stage IIIA. There was 1 postoperative complication (2.5%) and no intraoperative complications. Median time to discharge and to start chemotherapy was 5 days and 23 days respectively. After a median follow-up of 60 months, 3 patients (8.3%) were lost to follow-up and the remaining 33 patients were analysed for survival outcomes. The overall survival (OS) and recurrence-free survival (RFS) were 58.3% and 36.1% respectively. The median RFS and OS were 24 months and 51 months, respectively. Most recurrences involved the peritoneum (82.6%), and 5 patients (21.7%) had nodal recurrence alone. Laparoscopic optimal interval cytoreduction is feasible in patients with advanced ovarian cancers provided the disease burden permits optimal surgery, especially in centres with expertise in complex laparoscopic procedures.

Parietal Peritoneal Flap for Post-radiation Bladder Injury Repair.

Inadvertent bladder injuries during pelvic surgery are not uncommon. Repair of these cystotomies are generally easy. However, post-radiation, the urinary bladder becomes contracted, friable and difficult to heal. Injuries in this setting present a treatment dilemma especially when there is absence of viable native tissue such as omentum for tissue buttress. The authors report a case of parietal peritoneal flap for post-radiation bladder injury repair based on twigs from the inferior epigastric vessels. This flap being easy to perform is believed to be a viable alternative to musculocutaneous flaps especially in the emergency setting.

GATA-3 Expression in all Grades and Different Variants of Primary and Metastatic Urothelial Carcinoma.

Urothelial carcinoma has a varied and wide histological spectrum posing a diagnostic challenge in H&E examination alone. Immunohistochemical markers like GATA-3 along with other appropriate panel of IHC can be used. However, the percentage positivity and its intensity may vary in different variants and grades of primary and metastatic urothelial carcinoma. To observe the GATA-3 expression patterns in all the grades and different variants of primary and metastatic urothelial carcinomas. It is a prospective and retrospective observational study. All the clinically suspected urothelial carcinoma (UC) during January 2016 to December 2017 were included in the study. Depending on the differential diagnosis considered, immunohistochemistry (IHC) markers including CK7, CK20, p63, AMACR, CDX2, and p16 were done to differentiate UC from other primary carcinomas. The tumors confirmed as UC were analyzed further for GATA-3 expression by Chi-square test. The number of UC in the present study was 126 including 122 (bladder in 107, ureter in 7, renal pelvis in 5, and urethra in 3) primary and 4 metastatic UC (3 in lung and 1 in liver). Age of the patients ranged from 29 to 80 (mean 61.28) years with male/female ratio 4:1. GATA-3 showed positivity in 97 (79.5%) primary UC. GATA-3 was positive in all normal urothelium and non-invasive UC (100%), while it was positive in 69/94 (73.4%) invasive UC including variants. GATA-3 was positive in 35/39 LP invasive (89.74%) and 34/55 (61.81%) MP invasive UC. GATA-3 was positive in 39/40 papillary cases (97.5%) and 45/59 (76.27%) cases of non-papillary UC. GATA-3 showed strong expression in all metastatic UC (100%). GATA-3 expression was seen in 101/126 (80.15%) of UC including primary and metastatic carcinomas and hence was a useful marker in diagnosing UC. The GATA-3 positivity decreased from normal urothelium to UC; low-grade UC to high-grade UC; non-invasive to invasive UC; lamina propria invasive to muscle invasive UC; papillary to non-papillary UC.

Laparoscopic Repair of Acute Post-Esophagectomy Diaphragmatic Herniation Following Minimal Access Esophagectomy.

This study's objective was to assess the presentation, incidence, operative approach, and outcomes of acute symptomatic post-esophagectomy diaphragmatic hernia (PEDH), following minimal access esophagectomy (MAE) for esophageal and gastro-esophageal junctional cancer. Between January 2010 and December 2020, all consecutive patients undergoing esophagectomy were retrospectively analyzed. Acute symptomatic PEDH occurred in 4 patients out of 680 consecutive patients undergoing esophagectomy (0.58%) and 636 MAE (0.63%). All patients were men, with a median age of 56.5 years, and underwent minimal access transhiatal resection. The presentation was varied; 2 had restlessness, agitation, and tachycardia; one acute respiratory distress; and the last was asymptomatic but had reduced air entry over left hemithorax with unexplained hypoxia. All had transverse colon herniation into the left hemithorax. Herniated viscera were reduced with closure of hiatal defect, 3 underwent laparoscopic repair, and one needed laparotomy. Meshplasty or bowel resection was not required. The median hospital stay was 9 days with no perioperative mortality. The major complications (Clavien-Dindo grade ≥ IIIa) occurred in 2 patients. One patient was lost to follow-up, 2 died of disease after a year and 15 months post-procedure, and one is doing well at 10 months without any relapse of hernia. Acute symptomatic PEDH is a rare complication after transhiatal esophagectomy and mainly occurs in the left hemithorax. The incidence appears to be less than 1% after MAE. Laparoscopic repair is feasible in most cases. We recommend routine assessment of hiatus and tightening of hiatus to snuggly accommodate the gastric conduit.

A Randomized Trial Comparing the Efficacy of Methylene Blue Dye Alone Versus Combination of Methylene Blue Dye and Radioactive Sulfur Colloid in Sentinel Lymph Node Biopsy for Early Stage Breast Cancer Patients.

Although sentinel lymph node biopsy (SLNB) has become a standard of care for management of axilla in breast cancer patients, the technique of SLNB is still not well defined. Unlike radioactive sulfur colloid which requires nuclear medicine facilities, methylene blue dye is readily available. The purpose of this study is to validate the use of methylene blue dye alone for SLNB in early breast cancer patients. 60 patients of early breast cancer were randomized to receive either methylene blue alone (Group A-30 patients) or a combination of both methylene blue and radioactive colloid (Group B-30 patients) for detection of sentinel lymph nodes. Sentinel lymph node biopsy was done followed by complete axillary dissection in all patients. In both Groups A and B, sentinel node was identified in all 30 patients, giving identification rate of 100%. In group A, sentinel node was the only positive node in 1 patient, with a false-positive rate of 14.2%. The negative predictive value was 91.3%. The sensitivity of the procedure in predicting further axillary disease was 75% with a specificity of 95.45%. The overall accuracy was 90%. In group B, sentinel node was the only positive node in 2 cases, giving a false-positive rate of 28.7%. The negative predictive value was 95.65%. The sensitivity of the procedure in predicting further axillary disease was 83.33% with a specificity of 91.67%. The overall accuracy was 90%. Although the false-negative rate was slightly higher with methylene blue alone than that using combination (8.6%-4.3%), it was statistically insignificant. Similarly the sensitivity (75%-83.33%), specificity (95.45-91.67%), and negative predictive value (91.3%-95.67%) were also comparable between groups A and B, respectively. Negative predictive value and false-negative rates are comparable, whether blue dye is used alone or a combination of blue dye and radioactive colloid is used. Sentinel lymph node biopsy with blue dye alone is reliable and can be put to clinical practice more widely, even if nuclear medicine facilities are not available in resource constrained centers, so as to reduce long-term morbidity of axillary dissection, with similar oncological outcomes.

Gingival Angiosarcoma: A Case Report and Clinicopathologic Review of 32 Cases of Primary Gingival Angiosarcoma.

Angiosarcoma is a malignant neoplasm of mesenchymal origin arising from vascular endothelium and most commonly involves extremities. Gingival angiosarcoma is a rare sporadic occurring tumor. We report a case of primary angiosarcoma of gingiva along with a review of 31 cases of primary gingival angiosarcoma reported in literature till 2018. A 30-year-old lady presented with recurrent gingival swelling over central mandible. She had no palpable cervical lymphadenopathy. She underwent central marginal mandibulectomy. Final histological analysis with immunohistochemistry was suggestive of the angiosarcoma of the gingiva. She is 50 months postoperative and doing well.

Ewing Sarcoma With Emphasis on Extra-skeletal Ewing Sarcoma: A Decade's Experience From a Single Centre in India.

INTRODUCTION: The diagnosis of Ewing sarcoma family of tumours (ESFT) is challenging, especially in adults and in extra-skeletal or visceral location. Several morphologic mimics with varied treatment options and prognosis confer diagnostic dilemmas. Application of ancillary diagnostic modalities in surgical pathology in clinical routine has enabled accurate diagnosis of ESFT in bone, soft tissues, and viscera. AIM: The study aims to assess the clinicopathological features including molecular test results of ESFT with emphasis on sex, age, and location, especially extra-skeletal soft tissue and visceral location. MATERIAL AND METHODS: Data of clinicopathological, molecular tests (wherever performed), diagnosis rendered in 302 ESFT over a decade from our centre were reviewed. Statistical comparison of skeletal and extra-skeletal tumours with reference to age and sex was done using SPSS package. The P value of <.05 was considered significant. RESULTS: The cohort included 302 ESFTs with 49% skeletal and 51% extra-skeletal tumours. Thigh was most common site among skeletal tumours; chest wall, paraspinal location, and retroperitoneum among soft tissues (39.4%); and kidney, ovary, and cervix among visceral tumours (11.3%). Fluorescence in situ hybridisation for EWSR1 gene rearrangement was positive in 54 patients and reverse-transcriptase polymerase chain reaction in 19 patients. Predominance of male sex, younger age and location in extremities among skeletal tumours and lack of gender predilection, higher age and axial location in extra-skeletal tumours were noted, which were statistically significant. Molecular tests were performed more frequently in extra-skeletal tumours, especially in visceral tumours to establish the diagnosis. CONCLUSIONS: The study showed statistically significant differences in the age, sex, and location between skeletal and extra-skeletal ESFT. The increased percentage of extra-skeletal tumours especially in viscera was attributed to the increased awareness and availability of ancillary techniques.

Prospective Randomized Controlled Study Comparing Primary Surgery Versus Neoadjuvant Chemotherapy Followed by Surgery in Gastric Carcinoma.

Neoadjuvant chemotherapy in gastric cancer can treat micro metastatic disease and can increase the resectability rate. The trial was to compare early outcomes after primary surgery versus neoadjuvant chemotherapy followed by surgery in gastric adenocarcinoma. The primary aim of the study was to compare resectability and R0 resection rates in upfront surgery v/s chemotherapy followed by surgery arm. A secondary aim was to see if neoadjuvant chemotherapy is well tolerated or not by comparing postoperative morbidity and mortality. The study consisted of 60 consecutive patients of carcinoma stomach randomized into primary surgery and neoadjuvant chemotherapy followed by surgery arms. Morbidity, pathological status, and mortality data were collected and analyzed. Mean operating time in primary surgery arm was 290 ± 46.5 min, while in NACTarm, it was 316.7 ± 56.6 min, respectively. When postop complications were compared between the arms, it was not significant. Comparing the histopathological report of two groups, there was no significant difference between differentiated, T stage, mean lymph node harvest, R0 resection, PNI, and LVI. Neoadjuvant chemotherapy showed a trend towards improving in the R0 resection rate. There is no increase in postoperative morbidity and mortality with neoadjuvant chemotherapy.

Anaplastic lymphoma kinase status in lung cancers: An immunohistochemistry and fluorescence in situ hybridization study from a tertiary cancer center in India.

BACKGROUND AND OBJECTIVES: Fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) have shown good concordance for the detection of echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase (ALK) rearrangement. Since studies reporting FISH/IHC concordance, clinicopathological features, and clinical outcomes of ALK-positive patients from India are lacking, this study was undertaken. MATERIALS AND METHODS: This is a retrospective, observational study of patients with adenocarcinoma of the lung on whom ALK test was performed between March 2013 and December 2015. ALK status was assessed in 341 patients by FISH using Vysis ALK Dual Color Break Apart Rearrangement Probe and IHC using ALK D5F3 clone. Clinicopathological features were noted. Patients were managed as per the standard guidelines. Clinical outcomes - response rate (RR) and progression-free survival (PFS) - were measured. RESULTS: ALK rearrangement was positive in 37 patients (10.9%). ALK positivity was observed more commonly in younger patients with no predilection for any gender or any specific histological subtype. ALK by IHC was highly sensitive (100%), compared to FISH with concordance rate of 94.4%. Thirty one of thirty seven (31 of 37) patients received therapy of which 3 patients received palliative chemotherapy and 28 patients received tyrosine kinase inhibitors (crizotinib/ceritinib). Overall RR observed was 77.4%, and median PFS had not been reached at a median follow-up of 12.5 months. INTERPRETATION AND CONCLUSIONS: We report higher frequency of ALK positivity (10.9%) in patients with adenocarcinoma of the lung. ALK by IHC is more sensitive than FISH for ALK detection with high concordance. These patients had good clinical outcome with TKIs targeting ALK fusion protein.