A Descriptive Analysis of Patients Undergoing Cytoreductive Surgery for the First Peritoneal Recurrence from Adult Granulosa Cell Tumours: Focus on Disease Distribution, Morphology of Peritoneal Disease and the Role of HIPEC - a Retrospective Study by INDEPSO.

The aim of the present study was to report the clinical outcome and factors affecting survival in patients with first recurrence of AGC treated with cytoreductive surgery with or without HIPEC. The second aim was to study the disease distribution in the peritoneal cavity according to the peritoneal carcinomatosis index (PCI) and the morphology of peritoneal deposits. In this retrospective multicentric study, all patients of adult granulosa cell tumor with peritoneal recurrence were treated with CRS with or without HIPEC. Relevant clinical and demographic data were captured. Multivariable logistic regression was performed to evaluate the factors affecting recurrence after CRS ± HIPEC. Factors affecting survival and second recurrences were evaluated in addition to studying the disease distribution at first recurrence. In the period from January 2013 to December 2021, 30 consecutive patients of recurrent adult type granulosa cell tumor of the ovary undergoing CRS ± HIPEC were included in this study. The median follow-up duration was 55 months [12-96 months]. The median rPFS and rOS were both not reached. HIPEC (p = 0.015) was the only factor independently associated with a longer rPFS. CRS with or without HIPEC can be performed with an acceptable morbidity in patients with the first recurrence from adult granulosa cell tumours. The role of HIPEC, patterns of peritoneal spread and impact of other prognostic factors on the treatment outcome all need further evaluation in larger series of patients.

Cytoreductive Surgery With or Without HIPEC in the Management of Peritoneal Dissemination from Rare Histological Subtypes of Ovarian Cancer - a Retrospective Study by INDEPSO.

The aim of this study was to evaluate the potential role of optimal cytoreductive surgery with or without HIPEC in the management of peritoneal dissemination from rare histological subtypes of ovarian cancer and to report the prognostic factors affecting survival. In this retrospective multicentric study, all patients with diagnosis of locally advanced ca ovary with histology other than high-grade serous carcinoma and those having undergone cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy for the same were included. Factors affecting survival were evaluated in addition to studying the clinicopathological features. In the period from January 2013 to December 2021, 101 consecutive patients of ovarian cancer with rare histology underwent cytoreductive surgery with or without HIPEC. The median OS was not reached (NR), and the median PFS was 60 months. On evaluation of factors affecting overall survival (OS) and progression-free survival (PFS), PCI > 15 was associated with not only a decreased PFS (p = 0.019) but also a decreased OS (P = 0.019) on univariate and multivariate analysis. With respect to histology, the best OS and PFS were seen with granulosa cell tumor, mucinous tumors for which median OS and median PFS were NR respectively. Cytoreductive surgery can be performed with an acceptable morbidity in patients with peritoneal dissemination from ovarian tumors of rare histology. The role of HIPEC and impact of other prognostic factors on the treatment and survival outcome need further evaluation in larger series of patients. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01640-5.

Standardised Critical Care Strategies Improve Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in an Indian Peritoneal Malignancy Centre.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major undertaking with profound peri-operative metabolic and haemodynamic alterations. It requires standardised protocols for immediate postoperative intensive care management to improve patient-related outcomes. A retrospective analysis of a prospectively maintained data-base of 244 patients who underwent CRS and HIPEC between June 2017 and July 2022 in our institute was done. Based on the audit, six strategies were implemented, namely, (1) dynamic multiparameter-based IVF therapy to aggressively correct the hyperlactatemia, (2) initiation of IV 20% human albumin infusion from POD-0, (3) correction of serum iCa2+ levels, (4) initiation of diuresis from POD-1, (5) prophylactic use of HFNO immediately post-extubation and (6) serum procalcitonin level-based empiric escalation of IV antibiotics. Patients were divided into two cohorts, pre-protocol group of 145 patients (from June 2017 to December 2020) and post-protocol group comprising of 99 patients (from January 2021 to July 2022), and were analysed for compliance and patient-related outcomes. Implementation of these strategies improved the patient-related outcomes among the two cohorts with significant reduction of Clavien-Dindo grade III/IV complications and improvement in failure to rescue (FTR) index (p < 0.05). There was highly significant reduction in median ICU and hospital stay among the two cohorts (p < 0.001). The formulated protocols of management strategies especially multiparameter-based dynamic fluid therapy, planned diuresis and prophylactic HFNO have improved the outcomes in our patients undergoing CRS and HIPEC.

Sentinel Lymph Node Biopsy by Lymphatic Flare Technique: a Feasibility Study-"The FLAIR Is in the FLARE".

Background: Sentinel lymph node (SLN) biopsy is a standard procedure in evaluating the status of node negative axilla. Numerous techniques have been described in literature. We hereby describe a new technique of intradermal injection of blue dye called the lymphatic flare technique. Methods: The study was conducted in two phases over a year from August 2020 to May 2021with an internal audit to validate and standardize the technique in January 2021. Results: Between August 2020 and December 2020, 32 patients were evaluated for validation of this technique by two senior surgeons, which yielded a SLN identification rate of 93.75% (30 out of 32). After validating, standardizing, and educating the entire surgical team of the technique, another consecutive 27 patients were evaluated. The SLN identification rate increased to 100% (27 out of 27). Overall, SLN positivity for cancer was 16.6% (10 out of 60). Conclusion: SLN identification by the lymphatic flare technique is feasible, accurate, and reproducible.

Clinico-pathological Study of Limb Salvage Surgery for Osteosarcoma: Experience in a Rural Cancer Center.

Although recent multimodality therapeutic protocols have led to improved survival in osteosarcoma (OS), the outcome still remains dismal. Ongoing international multicentric trials on OS aim to randomize patients for optimum management, based on histological response to NACT. The pathologic response to neoadjuvant chemotherapy (NACT) is the most important factor predicting prognosis. In this study of 23 cases of limb salvage surgery post neoadjuvant chemotherapy, mean age was 18.3 years, with male predominance. 65.5 % cases were conventional OS. Histologic assessment of chemotherapeutic effect done by Huvos grading revealed good response (Huvos lll and lV) in 15 (65.2 %) and poor response (Huvos l and ll) in eight (34.8 %). A scoring based on MRI with a scale of 1-6 was compared with histologic response. Five (62.5 %) of poor responders showed score of >3 and 73.3 % of good responders showed ≤3. Dose intensity of NACT was calculated and correlated with the histological response. 53.3 % of good responders showed ARDI > 0.9. Five (21.7 %) developed local recurrence and 10(43.4 %) had pulmonary metastasis. Adoption of more aggressive treatment modalities may ensure better histologic response and longer event free survival.

Pelvic exenteration: experience from a rural cancer center in developing world.

BACKGROUND: Pelvic exenteration (PE) is a morbid procedure. Ours is a rural based cancer center limited trained surgical oncology staff. Hence, this audit was planned to evaluate morbidity and outcomes of all patients undergoing PE at our center. METHODS: This is a IRB approved retrospective audit of all patients who underwent PE at our center from January 2010 to August 2013. The toxicity grades were retrospectively assigned according to the CTCAE version 4.02 criteria. Chi-square test was done to identify factors affecting grades 3-5 morbidity. Kaplan Meier survival analysis has been used for estimation of median PFS and OS. RESULTS: 34 patients were identified, with the median age of 52 years (28-73 years). Total, anterior, posterior, and modified posterior exenterations were performed in 4 (11.8%), 5 (14.7%), 14 (41.2%), and 11 (32.4%) patients, respectively. The median time for surgery was 5.5 hours (3-8 hours). The median blood loss was 500 mL (200-4000 mL). CTCAE version 4.02 grades 3-4 toxicity was seen in nine patients (25.7%). The median estimated progression free survival was 31.76 months (25.13-38.40 months). The 2-year overall survival was 97.14%. CONCLUSION: PE related grades 3-5 morbidity of 25.7% and mortality of 2.9% at our resource limited center are encouraging.

Unique surgical issues in the management of a giant retroperitoneal schwannoma and brief review of literature.

Ancient Schwannoma, though benign, can cause diagnostic dilemma because of its clinical presentation and imaging features. We report the management of a giant retroperitoneal schwannoma in a 19-year-old young lady who presented with lower abdominal distension. CT scan reported a large heterogenous lesion in the abdominopelvic retroperitoneum (42 cm × 16 cm × 16 cm) as a malignant tumor. The unique problems we encountered were the enormous size, the location of major part of the tumor in the pelvis, the need for fertility preservation, the external iliac vessels stretching over the tumor making mobilization surgically demanding, and the prospects of neurological deficits. An en bloc resection of schwannoma with common iliac, external iliac and internal iliac veins, internal iliac artery, femoral and obturator nerves, and iliopsoas muscle was done maintaining oncological principles. External iliac artery that was cut to facilitate tumor mobilization was reanastomosed at the end of the procedure. Postoperatively patient had uneventful recovery with patchy sensory loss, foot drop, and quadriceps weakness which was rehabilitated with a foot drop splint and active physiotherapy.

Gastric carcinoma-a rare presentation.

Over the last 10 years there has been increasing evidence of a strong association between Idiopathic Deep vein thrombosis (IDVT) and occult malignancy. A review of world literature puts this new clinical entity as 4 -25%10. This mandates screening all cases of IDVT for a hidden malignancy. We report a case of advanced gastric carcinoma presenting as upper limb DVT with pulmonary embolism.