1) Title—Correlation of high 18-F FDG uptake with clinical and histopathological factors in primary breast cancer.
Authors—Sanchety N, Kannan N, Choudri S, Takkar P, Kulshreshtha P, Batra S.
Institute—Army Hospital (Research & Referral), Delhi Cantt, Delhi. naveeensanchety@gmail.com
Keywords—18-F FDG PET/CT, SUV, breast cancer
Introduction: 18-F FDG uptake is an independent prognostic factor for relapse-free survival, lymph node positivity and histological grade. High FDG uptake has the potential to select patients for aggressive chemotherapy and prognosticate the patients accordingly.
Aim: The aim of the study was to determine the impact of clinical and histological factors in breast cancer on 18-F FDG uptake on PET/CT. Methods: In our prospective study 72 patients (71 females and 1 male) were included. All patients underwent staging investigations including WBPET/CT before starting therapy. SUV (max) values were compared with various clinical and pathological features. Results: In a univariate analysis ‘T’ stage had no influence on SUV (max) values. When cut-off values of SUV (max) was taken as >/=2.5, the sensitivity and specificity of PET/CT for N stage were 81.25% and 100% respectively. SUV (max) values of metaplastic lesions were higher than that of ductal / lobular carcinoma. Median SUV (max) values of high grade tumors were 10.6 vs. 5.4 of low grade tumors. SUV (max) values of estrogen negative tumors were higher (9.9 vs. 6.1) than that of estrogen positive tumors. Triple negative breast cancers had higher FDG uptake (10.4 vs. 6.7). Lesions with estrogen receptor (-ve) and HER/2-neu receptor (+ve) had higher uptake as compared to ER (+ve) and HER/2-neu(-ve) (9.7 vs. 5.4). Conclusion: High uptake of 18F-FDG can be predictive of poor prognosis (high grade, hormone receptor negativity, triple negativity, metaplastic tumors) in patients with primary breast cancer. 18F-FDG PET/CT could be a useful tool to pre-therapeutically predict biological characteristics and baseline risk of breast cancer.
2) TITLE- Soft tissue sarcoma of extremity, a case series
AUTHOR’S NAME- Dr. Amit sinha Dr. Bitan kumar Chattopadhyay & Dr. Diptendra kumar Sarkar
INSTITUTE- IPGME&R & SSKM Hospital, Kolkata. babai8523@yahoo.in
KEY WORDS- Surgery is the mainstay of treatment of soft tissue sarcoma of extremity
INTRODUCTION- Soft tissue sarcomas are malignant tumors that may arise in any of the mesodermal tissues of the extremities (50%), trunk and retroperitoneum (40%), or head and neck (10%) or in GIT (GIST)
AIMS & OBJECTIVES-
To note different presentations of sts of extremity
To find out appropriate treatment options
METHODS- Taking patients with suspected or diagnosed cases of soft tissue sarcoma(sts) of extremity
RESULTS- Results were convincing . All the patients underwent limb saving surgery
CONCLUSION-Surgery is the mainstay of treatment and limb can be saved without sacrificing
DISCUSSION.
3) Title :ANTERIOR SKULL BASE RECONSTRUCTION AFTER CRANIO-FACIAL RESECTIONS
Author :
Ibrahim M, Balalgopal PG, Sebastian P
Hospital / institute :
Regional Cancer Centre, Trivandrum, India. mdibrahimdr@yahoo.co.in
Keywords : Skull base reconstruction, cranio-facial resections, fascia lata graft or abdominal pad of fat and galaea apponeurotica.
Introduction :
The tumors of the anterior cranial can be malignant or benign. The malignant tumors in this group include tumors that arise in the nasal cavity and paranasal sinuses like Esthesioneuroblastoma, squamous cell carcinomas arising in the paranasal sinuses, lymphomas.
Aims and objectives :
To present our method for anterior skull base reconstruction after oncological resections for malignant tumours in a low resource set up
Methods and materials :
Study group : 9 patients
Study period :2007–2009.
Limited dural defects were closed primarily or reconstructed using temporalis fascia.
Large anterior skull base defects were reconstructed by fascia lata graft or abdominal pad of fat and galaea apponeurotica.
Result :
Male Female ratio was 8:1.
Esthesioneuroblastoma- 4
PNS tumours( squamous cell carcinoma)- 3
Sino nasal teratocarcino sarcoma- 1
Meningioma- 1
No CSF leak or meningeal infection. Two patients died during the follow up period
Conclusion :
This is a simple and very effective method of anterior skull base reconstruction. This technique can be used for dural repair with no reported complications.
Discussion :
Cranio-facial resections are major surgeries which need major reconstructive procedures. Reconstruction with fascia lata graft, abdominal pad of fat and galaea apponeurotica is one of the effective method with good results.
4) TITLE—Outcome of radical cystectomy and ileal conduit in carcinoma of urinary bladder
AUTHOR—Dr Maheshkumar V.K
INSTITUTION—KMIO, Bangalore. mahesh.kalloli@gmail.com
BACKGROUND
Cancer of urinary bladder accounts to about 1–2% of all male cancers and 0.3–0.4% of all female cancers at our institute. Around 20–30 patients per year undergo radical cystectomy and ileal conduit. In recent years, improvements in perioperative and postoperative care, and refinements in surgical technique, have led to considerably reduced morbidity and mortality following radical cystectomy and ileal conduit.
AIM OF THE STUDY
to analyse mortality, early and delayed morbidity following radical cystectomy and ileal conduit and compare with that of western literature.
MATERIALS AND METHODS
A 5 year retrospective study of urinary bladder cancer who underwent radical cystectomy and ileal conduit was done from January 2006 to March 2011. Data regarding postoperative complications were recorded and analysed.
RESULTS
70 patients were included in our study. The mean age of patients was 58.6 years (28–81). 61 (87.1%) patients in our study were men. Most common mode of presentation was hematuria 59(84.2%). 50(71.4%) were smokers. Most common site was left posteriolateral (26 pts).Transitional cell carcinoma was predominant histological type which was found in 54(77.1%) patients followed by poorly differentiated cancer 6(8.5%). 56(80%) were high grade. Most of our patients belonged to stage 2 (30 pts) followed by stage 3 (14 pts).We came across 0% operative mortality. Early morbidity was in the form of wound infection in 14(20%), pyelonephritis in 12(17%), urine leak in 3(4%), wound dehiscence in 3(4%), fecal leak in 2(2.8%), intestinal obstruction in 2(2.8%) and late morbidity was in the form of hydronephrosis in 7(10%), renal deterioration in 6(8.5%) and stoma problems in 4(5.7%).
CONCLUSION
We achieved 0% operative mortality rate which was significant when compared to western literature but morbidity rates in our study were comparable. Our study showed that with proper preoperative, intraoperative and post operative management, mortality and morbidity following radical cystectomy and ileal conduit can be significantly reduced
5. Title—Sphincter Preservation Surgery in Rectal carcinoma- Cancer Institute (WIA) experience
Authors—Dr. Balaji R, Dr. A.S. Ramakrishnan, Dr. B.J.Sunil.
Hospital/ Institute: Cancer Institute (WIA), Adyar, Chennai. drbalaji5@gmail.com
Key Words—rectal cancer, neoadjuvant chemoradiation, low anterior resection, Sphincter preservation, outcomes
Introduction: Sphincter preserving surgery (SPS) after neoadjuvant therapy is increasingly being done in low rectal cancers.
Aims and Objectives: To analyze the overall& disease free survival, recurrence rates& complications associated with sphincter preserving surgery(SPS) in low rectal cancer
Methods & materials: A retrospective analysis of patients with low rectal cancer who underwent SPS in our institution between 1991 to 2006.
Results: A total of 105 patients underwent SPS for low rectal cancer of which 61 had neoadjuvant therapy. The median overall survival(OS) was 50 months& median disease-free survival (DFS) was 48 months in these patients. There was no statistically significant difference in the 5-year-OS& DFS between patients who had SP when compared to abdomino-perineal resection (APR) (71.6% vs 65.3%; p = 0.2689 and 64.5% vs 63.2%; p = 0.5832 respectively). The overall and isolated local recurrence rates were comparable in patients who had SP& APR (30.5% vs34.9% and 4.7% vs 3.7% respectively). The major complication rates were 21.9%& 14.7% following SP and APR respectively.
Conclusion: Sphincter preserving surgeries are oncologically& technically safe procedures in patients with low rectal cancer.
Discussion: Sphincter preserving surgeries are the standard of care in these days with neoadjuvant chemoradiation making them possible in higher numbers.
6) Title—MALE BREAST CANCER IN INDIAN PATIENTS : IS IT THE SAME ??
Author—Dr. Santosh. B.Chikaraddi, Mch PG (surgical oncology)Institution - Kidwai Memorial Institute of oncology, Bangalore. santu249@yahoo.co.in
BACKGROUND: Cancer of the male breast accounts for about 0.2–1.5% of all malignancies in men and 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. This study was done to analyse the demographic data, management and survival of male breast cancers in Indian subset of patients and compare it with that of wester n literature and with female breast cancers.
METHODS: A 10 year (2001–2010) retrospective study of all male breast cancers was done. Data regarding the incidence, presentation, histopathology, stage and grade of tumor , management and outcome of patients were analysed .
RESULTS: 26 cases of male breast cancer were encountered. This comprised 0.4% of all breast cancers seen in our department during the 10 year period. The ages of patients ranged from 45 to 75 years with a mean age of 57 years. Delay in patient presentation to physician ranged from 2 to 48 months. Family history was present in 4 patients. Clinically, symptoms included self-detected lump in 24 (92%) patients, nipple discharge or retraction in 9 (34%) and pain in 12 (50%). All cases were unilateral (15 on right ,9 on left) .Disease most commonly involved central quadrant (8 pts). Invasive ductal carcinoma was the predominant histological type . Grade 3 disease was found in 13 pts and Stage 3 disease was most commonly encountered (13 pts).none of our pts received neo adjuvant chemotherapy. 20 (77%) patients had modified radical mastectomy and 6 (23%) had radical mastectomy . Most of our pts were hormone receptor positive (17 pts). Bilateral orchidectomy , Tamoxifen, adjuvant chemotherapy and radiotherapy were offered in 3(11.5%), 15(57%), 16 (61%) and 17 (65%) patients respectively. Follow up ranged from 20 days–59 months.
CONCLUSION: Male breast cancer is rare in our centre. Late presentation with advanced disease is a common feature in our environment. Further randomized studies are needed to for better understanding of management of male breast cancers in Indian subset of patients.
Key words—Male breast cancer
7) Title—PRIMARY SYNCHRONOUS BILATERAL BREAST CANCER IN INDIAN PATIENTS
Author—Dr. Krishnappa.R , Mch PG ( surgical oncology)
Institution - Kidwai Memorial Institute of oncology, Bangalore. krishna1.322@rediffmail.comn
Background
Primary synchronous bilateral breast cancer (PSBBC) is a rare clinical entity The reported incidence ranges between 0.3% and 12%. There are several controversial issues regarding PSBBC pertaining to the diagnostic criteria, nomenclature, and management policies.
Materials and methods
Fourteen cases of PSBBC treated between 2001 to 2010 at Kidwai memorial institute of oncology were retrospectively analysed in regards to demographic data, management and survival.
Results
PSBBC constituted around 0.19% of total breast cancer patients at our institute. Age of patients ranged from 28 to 78 years and mean age being 40 years. Family history of breast cancer was present in five patients (16%) only. PSBBC were detected by clinical examination in all cases in our study . Most PSBBC patients had disease belonging to stage 2 and stage 3. All patients were found to have invasive ductal carcinoma, and none of the patients had lobular carcinoma.8 patients had triple hormone receptor negative disease. 3 patients received neoadjuvant chemotherapy.Twelve patients underwent bilateral modified radical mastectomy , one had unilateral mastectomy on one side and breast conservation on the other side, One patient has bilateral breast conservation . Sixteen patients had unilateral and six had bilateral adjuvant radiotherapy. Nine patients received adjuvant chemotherapy. 5 patients received adjuvant hormonal therapy. At a median follow up of 15.4 months (2–27 months), 13 (92%) patients were disease free and one (8%) patient had disease relapse in the form of chest wall recurrence.
Conclusion
PSBBC is an uncommon clinical entity. These patients require individualized treatment planning based on the tumor factors and treatment factors of the index lesion.
Key words—Bilateral breast cancer
8) Title: Impact of pathological nodal status after neoadjuvant treatment on the outcome in rectal cancer
Authors: B Jayanand Sunil, A S Ramakrishnan
Institute: Cancer Institute (WIA), Adyar, Chennai. drsunilbjs@yahoo.co.in
Key words: Neoadjuvant , rectal cancer, chemoradiation, nodal stage, chemotherapy
Introduction: The current NCCN guidelines recommend adjuvant chemotherapy in all patients with stage II or III rectal cancer after neoadjuvant chemoradiation regardless of the surgical pathology results, although its role is not well defined.
Aims and Objectives: The aim of the study was to analyze the impact of regional lymph nodal status after neoadjuvant treatment on survival outcomes in rectal cancer, and to try and identify patients who may not benefit from adjuvant chemotherapy.
Methods: We retrospectively analyzed 225 patients with rectal cancer who received neoadjuvant therapy followed by radical surgery in our institution between 1991 and 2006. The patients included in the study were staged clinically as cT2-T4 and/or cN+ before starting treatment. Patient and treatment related details were obtained from the records and the impact of the final postoperative pathological status (yp) on recurrence and survival were analyzed.
Result: Of the 225 patients who received neoadjuvant treatment, 208 patients received chemoradiation and 17 patients received only radiation. The (yp) stage distribution was as follows: stage I, stage II and stage III-49, 60 and 89 patients respectively. The 5-year actuarial disease free survival (DFS) and 5-year actuarial overall survival (OS) in patients with Stage I,II and III were 81.8%, 68.4%,41.8% and 85.5%, 71.9% and 46.2% respectively. Node negative patients had a significantly higher 5-year DFS and OS compared to node positive patients ( 75.7%vs 41.8%,p < 0.001). Patients with stage I disease after neoadjuvant therapy had a significantly lower distant failure rates compared to those with stage III disease ( 8.2%vs 33.7%,p = 0.0001).
Conclusion: Pathological node negative status after neoadjuvant therapy in rectal cancer has a favourable outcome when compared to node positive status. In view of the relatively low incidence of distant failure and an improved survival in patients with stage I disease after neoadjuvant therapy, the role of adjuvant chemotherapy in this subgroup of patients needs to be redefined by well conducted randomized controlled trials.
9) Title—Malignant triton tumor of the proximal femur successfully treated by total femoral replacement
Authors Kannan N, Sharma Y, Batra Swati, Takkar P, Kulshreshtha Pranjal, Sanchety N.
Institute—Army Hospital (Research & Referral), Delhi Cantt, Delhi. majkannan@gmail.com
Keywords—triton, limb salvage, total femur replacement, improper surgery
Introduction: Malignant Peripheral Nerve sheath tumor with rhabdomyoblastic differentiation, a.k.a. Malignant Triton tumor is a rare neoplasm of the bone especially outside the setting of Von Recklinghausen Disease with an aggressive biology and poor prognosis. surgical violation significantly worsens the prognosis. Limb conservation for proximal thigh bone or soft tissue lesions by Total femur modular endoprosthetic replacement is rarely performed surgical procedure. Case Report: 36 year old male with a clinicoradiologically benign lytic lesion of the proximal femur, was treated as Giant Cell Tumour/ Aneurysmal Bone Cyst by curettage, bone grafting and prophylactic intra-medullary nailing at a peripheral hospital and was subsequently referred to our centre with a post-operative histopathological diagnosis of a high grade pleomorphic sarcoma. After excluding regional and distant metastases he was managed with neo-adjuvant chemotherapy followed by en bloc resection of the entire length of the femur, including the intra-medullary nail and previous surgical scar. Reconstruction was subsequently achieved with a modular total femur with rotating bipolar hinge knee megaprosthesis. Final histology confirmed Malignant Triton tumour with marrow involvement and clear margins. This was followed by adjuvant LRRT and chemotherapy. The patient is currently disease free and ambulatory at 1 year post-treatment. Conclusion Limb salvage with radical resection, total femur endoprosthetic replacement and aggressive adjuvant therapy is a desirable option for proximal thigh bone and soft tissue sarcomas with good functional and oncological results.
10) Title—Myriad presentations of porcelain gallbladder- Report of 6 cases
Authors—Dr. Sameer Gupta , Prof. Sanjeev Misra, Dr. Vijay Kumar , Prof. Nuzhat Husain
Institute – Chatrapati Shahuji Maharaj Medical University (CSMMU), Lucknow. sameerdr79@gmail.com
Introduction—Porcelain gallbladder is characterized by brittle calcified gallbladder wall. It has female predominance and prevalence ranging from 0.06 to 0.8%,. It is associated with an increased risk of gallbladder cancer (5–10%).
Aims & Objectives—The aim of this article is to present 6 cases of Porcelain Gallbladder with their varied clinical features, diagnostic workup and management.
Method & Materials—The records of 6 patients with porcelain gallbladder were reviewed. Demographic data, presenting symptoms, loco regional disease extent, radiographic findings, histopathology and clinical management were analyzed.
Result—All 6 patients were female (age—45–60 years). All showed transmural curvilinear calcification. All had coincidental gallstones. 2/6 patients underwent Radical cholecystectomy with no evidence of malignancy. 4/6 patients had metastatic disease, managed with symptomatic treatment.
Discussion—The incidence of porcelain gallbladder is 0.06%–0.8% of cholecystectomy specimens. It is associated with cholelithiasis in more than 95% of cases. According to the literature, selective mucosal calcification poses a significantly higher risk of cancer compared to diffuse intramural calcification but in our series, 4/6 patients of histopathologically proven malignant porcelain gallbladder showed transmural calcification while 2/6 with similar calcification were not malignant.
Conclusion—Porcelain gallbladder is an uncommon entity, even in North Indian Gangetic plains, which has one of the highest incidences of carcinoma gallbladder in the world. In view of diverse clinical presentations and aggressiveness of the entity, irrespective of the pattern of calcification porcelain gallbladder should be worked up and treated aggressively.
Key words—Porcelain gallbladder, malignant, calcification.
11) Title : Re-exploration after modified radical mastectomy for Carcinoma breast—A retrospective study
Authors : Dr. Md.Ibrahim, Dr. Chandramohan, Dr. Paul Augustine, Dr. Jem Prabhakar, Dr. Iqbal Ahamed, Dr. Sebastian P.
Hospital: Regional Cancer Centre, Trivandrum, India. mdibrahimdr@yahoo.co.in
Keyword: Re-exploration, modified radical mastectomy
Introduction:
Hemorrhage after MRM for Carcinoma breast is one of the most common complication. Incidence varies from 1 to 9%
Aims and objectives:
To study the pattern of bleeding and the factors affecting re-exploration in patients who underwent MRM for Carcinoma Breast.
Methods and materials:
Period of study :
Jun-2008 to may-2011 (36 months)
Inclusion criteria :
Patients who underwent re-exploration after MRM
Exclusion criteria :
Revision mastectomy
MRM with LD flap / SSG for cover
Breast conservative and reconstructive surgeries
Result :
Total MRM = 2239
Total Re-exploration = 44
Re-exploration Rate = 1.96%
Mean 1st POD drain in re-explored MRM = 304.06 ml.
NACT rate in Re-exploration after MRM = 54.54%
HT Rate in Re-exploration after MRM = 32/44 = 72.73%
Conclusion :
1st POD drain level is a significant factor for re-exploration
Significantly higher rate of re-exploration in patients with Systemic Hypertension and in those who received Neo-adjuvant Chemotherapy.
Diffuse ooze is more common in those who received NACT and chest wall bleeders and multiple bleeders are more common among those with Systemic Hypertension.
Discussion :
Re-exploration after MRM is one of the most common complication which can be predicted by the above risk factors.
12) Title : Diversion colostomy in Anterior resections in the management of Post NACTRT cases of Carcinoma Rectum
Authors : Dr. Md. Ibrahim, Dr. Chandramohan, Dr. Paul Augustine, Dr. Jem Prabhakar, Dr. Iqbal Ahamed, Dr. Sebastian P.
Institute: Regional Cancer Centre, Trivandrum, India. mdibrahimdr@yahoo.co.in
Keywords :Diversion colostomy, Anterior resections, Carcinoma Rectum
Introduction :
Neo-Adjuvant Chemo-radiation is the initial line of management of locally advanced cases of Carcinoma Rectum. Diversion colostomy is done to prevent the anastomotic leak in carcinoma rectum.
Aims and objectives:
To assess the need for temporary diversion colostomy in cases of rectal cancer who undergo anterior resection after neoadjuvant chemo-radiation.
Methods and materials :
Period of study :
Aug-2009 to march-2011 (20 months)
Inclusion criteria :
Patients who underwent Anterior resection with stapler anastomosis after undergoing NACTRT
Exclusion criteria :
Previous abdominal or pelvic surgery
Intestinal obstruction
Previous diversion colostomy
Laparoscopic AR
Result :
Total post NACTRT AR = 105
Low AR and Ultra low AR = 16
Diversion post-op for Grade-C anastomotic Complication = 6
Low AR and Ultra low AR who underwent Diversion = 3
Diabetes in all AR = 56
Diabetes in diverted group = 3
Conclusion :
There is no need for routine fecal diversion in all cases of rectal cancers who undergo Anterior resection after receiving neoadjuvant chemo- radiation.
Discussion :
Diversion colostomy can be kept as reserve for Anterior resection patients with risk factors like a Low AR and Ultra low AR and Diabetes mellitus.
13) TITLE: Prospective study of carcinoma breast with special reference to Clinical, Radiological & Pathological correlation of tumor size & nodal status in operable cases.
Author : Sharma Raj Govind, Galodha Saurabh, Patel Pinakin
Hospital : S.M.S. Medical College & Hospital, Jaipur. rajgovindsharma@gmail.com
Key words: Breast cancer, tumor size, axillary lymph node, mammography, USG
Introduction: Tumor size and Lymph node positivity are important prognostic factors in Carcinoma Breast. There is variation in assessment of size of tumor and Axillary Nodal Status, Clinically, Radiologicaly & on Histopathology.
Aims & objectives: Our aim was to study the difference in Clinical T size, Radiological (USG & Mammography) T size & Pathological T size of tumor and also the axillary nodal status and to find any correlation between T size & Node positivity.
Method &Material : The study includes 115 cases of breast cancer admitted in single surgical unit in Department of general surgery between Sep.2009 to Dec.2010 who underwent surgery (MRM in 107 cases & BCS in 8 cases) . Clinical, Radiological & Pathological comparison was made with regard to tumor size & nodal status to ascertain their accuracy. The association of positive axillary lymph nodes with tumor size was also studied and analyzed.
Results: Average T size in our study was 4.6 × 3.2 × 3 cm. When Histopathology was taken as the base line for tumor size, USG underestimated tumor size by approximately 6 mm where as Clinical examination overestimated T size by 9 mm. Average number of axillary lymph nodes removed was 15.3 in our study of which 53% had >4 positive nodes. Lymph node positivity on clinical assessment had sensitivity 68.2% and specificity 62.9%. In USG it had 77.7% sensitivity and 77.4% specificity. The positive predictive value was increased from 68.3% on clinical examination to 80.4% on USG. Tumor size >1 cm had positive lymph node in 53.7% cases.
Conclusions: It was concluded that small tumor size does not obviate the need for axillary nodal dissection completely & one should subject these patients to additional diagnostic work-up. USG is a modality which can help us predict the nodal status preoperatively fairly accurately. USG is a better modality to ascertain the preoperative tumor size & should be a part of all management protocols for carcinoma breast.
14) PANCREATIC INSULINOMA: OUR EXPERIENCE
Prof A. Basu1, Dr A. Ayaz2, Dr S. Rath3
IPGME&R and SSKM HOSPITAL, KOLKATA. asif2ks8@gmail.com
KEYWORDS: Insulinoma, Euglycemia, Intraoperative.
INTRODUCTION: An insulinoma is a tumour of the pancreas that is derived from beta cells and secretes increased insulin causing hypoglycaemic feature.
AIMS & OBJECTIVE: To describe our experience in the management of patients with pancreatic insulinomas, emphasizing the need for preoperative localization and the outcome of surgical treatment.
RESULTS In 6 patients with solitary tumors, most lesions detected or missed by preoperative localization could be either seen (n = 3) or palpated (n = 6). Intraoperative ultrasonography was not necessary because all the tumor were well palpable intraoperatively and were solitary. There was no operative mortality and major morbidity. Euglycemia was achieved in all the 6 patients. Surgery cured all patients with benign insulinomas. The type of surgical treatment or correct preoperative localization did not affect the outcome of surgery.
CONCLUSIONS: Pancreatic insulinomas can be readily localized intraoperatively despite failed preoperative localization studies. Surgical treatment cured benign adenomas.
DISCUSSION: Insulinomas are pancreatic islet cell tumors that are often benign but have a unique presentation associated with hypoglycemia with incidence of 4 cases per million persons/year.Diagnosis endogenous hyperinsulinemia requires the presence of nonsuppressed insulin and C-peptide with negative screening for sulfonylurea compounds and insulin antibodies.
1. Prof Abhimanyu basu, Dept of General Surgery, IPGMER,Kolkata
2. Dr Asif Ayaz, Post Graduate trainee, Dept of General Surgery, IPGMER, Kolkata
3. Dr Satyajit Rath, Post Graduate trainee, Dept of General Surgery, IPGMER, Kolkata
15) Title—Complications of More Than 1000 Total Thyroidectomy: An Experience from Specialized Thyroid Surgery Centre in North India
Authers- Gyan Chand, Sudhi Agarwal, Amit Agarwal, S.K.Mishra.
Hospital/Institute-
Department of Endocrine Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, UP, INDIA. 226014. gyan133@sgpgi.ac.in
Key words—Complications of thyroid surgery, Total Thyroidectomy, Thyroid Surgery
Introduction-
Total thyroidectomy (TT) by a uniform capsular dissection technique is the preferred method of surgery worldwide. Though it is safe but some time associated with specific complications, the details of which have been discussed scarcely in India, and the clubbing of complications of less than TT and TT underestimates the risk of latter, as done in various studies.
Aims & Objective- To analyse the complications and management of >1000 total thyroidectomy done as primary surgery at our centre.
Material/ Method- Retrospective study from a single centre specialized in thyroid surgery at north India. Data collected from hospital information system (HIS), department database registers, patient record files, correspondence, telephonic and personal communications.
Results—Total 1038 cases were found suitable for this study, mean age 42.91 ± 13.48 years; Male: Female- 1: 2.2; mean duration of goiter 99.83 ± 105.1 months; euthyroid- 67.8% and hyperthyroid- 30.7%; malignant- 35.5%; compressive symptoms- 21.9%; retrosternal extension- 12.5%; Surgery :-TT alone- 77.7% and TT with lymph nodes dissection- 22.3%; mean gross gland weight- 124.34 ± 129.85 g; tracheomalacia-3.9%, sternotomy -1.2%, thoracotomy – 0.1%, tracheostomy- 4.5%, parathyroid auto-transplantation- 21%; Complications- Hypocalcemia (temporary -35.9%; permanent- 1.3%); recurrent laryngeal nerve palsy (temporary- 2.7%; permanent- 1.3%); haemorrhage -1.3%; thoracic duct injury- 1%; inadvertent parathyroidectomy -6%; surgical site infection- 3.8%; wound related complications- 6.9%, tracheal stenosis- 0.1%, and other minor complications- 2.0%; Hyperthyroidism, Malignancy, lymph nodes dissection, large goiter with altered cervical anatomy and mediastinal goiter were associated with majority of complications.
Conclusion—Total thyroidectomy is a safe procedure. Certain risk factors may predispose to complications, which can be avoided and managed adequately if anticipated beforehand. Long term morbidity is 1-2% with practically nil mortality.
16) REPORT OF FOLLICULAR DENDRITIC CELL TUMOUR OF COLON AND REVIEW OF LITRETURE
Prof A. Basu1, Dr S. Rath2
IPGMER AND SSKM HOSPITAL KOLKATA. DRSATYAJITRATH@GMAIL.COM
Abstract
Introduction: Follicular Dendritic Cell Sarcoma (FDCS) is an extremely rare neoplasm.far too rare to occur in colon. While the existence of FDC tumors was predicted by Lennert in 1978, the tumor wasn’t fully recognized as its own cancer until 1986 after characterization by Monda et. al. It accounts for only 0.4% of soft tissue sarcomas, but has significant recurrent and metastatic potential and is considered an intermediate grade malignancy.
Case report: We report a case of FDC sarcoma arising in the colon. A 24-year-old female presented with pain in right iliac fossa. USG revealed iliocolic intussusception. CECT abdomen revealed ileo-colic intussusceptions with thickened ileal wall, multiple sizeable adherent globular masses having necrotic foci. On exploration there was a 5 × 4 cm mass in ascending colon with necrosis and infiltration to the surrounding tissue, paracolic lymph node palpable. Right hemicolectomy was performed. Microscopically, the tumor showed interlacing fascicles of spindle-shaped stromal cells with large oval and polygonal nuclei admixed with non- neoplastic small lymphocytes. Immunohistologically, the cells were positive for CD21,CD 23 and CD35, consistent with FDC sarcomas.
1. Prof Abhimanyu basu, Dept of General Surgery, IPGMER, Kolkata
2. Dr Satyajit Rath, Post Graduate trainee, Dept of General Surgery, IPGMER, Kolkata
17) Use Of Ultrasonic Shears In Patients With Breast Cancer Undergoing Axillary Dissection- A Pilot Study.
Dr Rakesh S Ramesh, Dr Suraj Manjunath, Dr Shivakumar K, Dr Roji Philip, Mrs Sumitha Selvum
Dept Of Surgical Oncology,St Johns Medical College Hospital And Research Centre,Bangalore, India -5600034. srakesh99@yahoo.co.in
Key Words: Ultrasonic Shears, Cautery, Axillary Dissection, Breast Cancer
Introduction: Patients with breast cancer and positive sentinel node biopsy usually require axillary dissection. Different instruments are used for axillary dissection like regular scalpel,monopolar cautery,bipolar cautery etc.All these instruments are having its advantages and disadvantages.
Aims And Objective: Our dept did a pilot study to know the efficacy of ultrasonic shears over cautery for axillary dissection.[1,2].Parameters considered were cumulative drain amount ,number of days with the drain and number of lymphnodes harvested
Materials and Methods:Ultrasonic shear machine delivers precisely directed mechanical energy with an ultrasonic vibrating blade. A single device dissects, cuts, grasps, spot coagulates.This machine was used for doing axillary dissection in one group and regular cautery in the other group.
Study period was from April 2011 to June 2011 at Dept of Surgical Oncology,St Johns Hospital, Bangalore.Nine people in the ultrasonic shear group and 11 people in the cautery group were included in the pilot study.
Results: No significant difference were noticed in the cumulative drain amount ,number of days with the drain,and number of lymphnodes harvested in both the groups.
Discussion &Conclusions: Axillary dissection using ultrasonic shears do not show any significant difference in the cumulative drain amount ,number of days with the drain, and number of lymphnodes harvested. These are the findings of the pilot study,further prospective randomized studies are required for substantiating the findings.
References:
1. Lumachi F et al. Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study. Eur J Surg Oncol 2004 ; 30 : 526–530.
2. Lumachi F et al. Usefulness of ultrasound scissors in reducing serous drainage after axillary dissection for breast cancer: a prospective randomized clinical study. Am Surg 2004; 70: 80–84.
18) Male breast cancer: A clinicopathologic study of 42 patients in Eastern India
S Shah, S Bhattacharyya, A Gupta, A Ghosh, S Basak
Cancer Centre Welfare Home & Research Institute, Kolkata. drsumitdshah@gmail.com
Key words: Male breast cancer, Carcinoma of male breast
Abstract
Objective: Retrospective review of presentation, treatment and outcome of male breast cancer in a tertiary cancer centre in eastern India. Method and Materials: Data of the 42 male breast cancer(MBC) patients who presented between April,2001 and March 2008 were collected from institute records with respect to epidemiological charecteristics,clinicopathological parameters, treatment pattern and outcome. Result: This series includes 42 patients .The mean age was 56 years (range 31–78 years). MBC represented 1.1% of all breast cancer. Most patients had lump as main symptom (80.95%). Duration of symptoms range from 1 month to 4 years. Histopathology found infiltrating ductal carcinoma in 35 (83.33%) patients, papillary carcinoma in 3 (7.14%) patients, undifferentiated carcinoma in 2 (4.76%) patients, mucinous carcinoma in 1(2.38%) patient, myxofibrosarcoma in 1(2.38%) patient. Hormonal receptor study was carried out in 29 (69.05%) patients; 26 (89.66%) were estrogen receptor (ER) positive and 18(62.07%) were progesterone receptor (PR) positive; 3(10.34%) were ER/PR negative. Among the 30 patients of axillary lymph node dissection 18(60%) were positive (pN+) and 12(40%) were negative (pN-). Of the patients with invasive carcinoma 2.86% were pathologic stage I, 37.14% stage II, 42.86% stage III and 17.14% stage IV. Of the 35 treated patients, total 30 (85.71%) patients underwent surgery. The surgery consisted of a modified radical mastectomy (MRM) 24(80% ), radical mastectomy according to Halsted (RM) 6(20%). Adjuvant chemotherapy and radiotherapy given according to stage. All hormone receptor positve patients received tamoxifen. Patients were followed up with minimum duration 17 months to maximum 136 months( mean 63.2 months). 4 patients developed local recurrence over 4 to 26 months (mean17.5 months) and 5 patients developed distant metastasis over 24 to132 months (mean 78 months). Disease specific survival varied from 4 months to 132 months , mean 56.75 months. 13 out of 28 evaluable patients (46.43%) were disease free at 5 years. Conclusion: MBC is a rare affection, still ignored in our environment. Most of the patients had advanced disease at presentation. In view of high estrogen receptor positive cancer in men, hormonal therapy needs to be strongly considered and multicentric prospective studies are needed to improve outcome.
19) Title : An Unusual Case of tumor distal Pancreas
Author/s : Sahu M , Chauhan A, Mathur M, Basu A
Hospital/Institute : Command Hospital (CC), Lucknow. mukul1974@yahoo.com
Key words: Pancreatic Neoplasms, Anaplastic carcinoma.
Introduction: Anaplastic pancreatic carcinoma is an aggressive neoplasm with survival measurable in weeks. It presents as a large cystic mass with loco-regional and distant spread. They have been described as pleomorphic carcinomas, pleomorphic giant cell carcinomas, spindle cell carcinomas, sarcomatoid carcinomas, and anaplastic (undifferentiated) carcinomas . We hereby describe a case of Anaplastic carcinoma with unusual presentation.
Aims & Objectives : To bring out the unusual presentation of anaplastic carcinoma pancreas.
Method & Materials : Clinical examination followed by CECT abdomen. Laprotomy done with diagnosis of Non functioning islet cell tumor. Specimen sent for histopathology.
Result : Histopathology diagnosed as Anaplastic carcinoma pancreas.
Conclusion : Despite of being an aggressive malignant tumor, it can present with such unusual symptoms.
Discussion: Anaplastic cancers of the pancreas rare aggressive tumors with incidence of 2–7% of all pancreatic cancers.Weight loss, fatigue, loss of appetite, abdominal pain, nausea, vomiting and diarrhoea are the usual clinical presenting symptoms. Rapid local and distant spread. Tumors of the body and the tail are more likely to give pulmonary rather than hepatic metastasis associated with poorer survival having only 3% 3-year survival, limited data available on treatment options.
20) Title :AN ATYPICAL CASE OF INTESTINAL OBSTRUCTION
Author :Dr. Prashant S Patil, Dr Diptendra K
Sarkar Hospital SSKM/IPGME&R, KOLKATA. docprashant2010@gmail.com
Key words :metastasis,EMT,Ductal cell carcinoma
Introduction :Breast cancer usually metastasises to lung,liver,bones,brain and uncommonly to intestine.There are very few reported cases of metastasis to small bowel from breast cancer. Metastasis to small bowel from breast cancer can present with chronic anaemia,subacute obstruction,acute obstruction,malena,altered bowel habits.We report a case of subacute intestinal obstruction due to metastasis from breast cancer for which patient was operated 5 yrs back.
Details of the case :
A 62 year old lady presented to surgical emergency with features of subacute intestinal obstruction,patient was managed conservatively but showed signs of peritonitis for which she was explored.On exploration we found a stricture in jejunum with a mass .Resection and anastomosis was done. HPE report from stricture and mass revealed metastatic ductal cell carcinoma of breast .Patient was started on palliative chemotherapy but died after 2 months.
Conclusion : Metastasis from breast cancer to small bowel can present as a diagnostic dilemma and diagnosis often is made by histopathological examination .
Discussion : Metastasis from breast cancer to small bowel is not common,and isolated metastasis to jejunum are much rarer. Possible mechanism of metastasis to small bowel can be explained by EMT (epithelial mesenchymal transformation) theory.
21) TITLE: ABDOMINAL TUBERCULOSIS MIMICKING DIFFUSE PERITONEAL CARCINIMATOSIS
AUTHOR: Prof. Osman Musa, Dr, Jagadamba Sharan, Dr. Arijit Roy, Dr. Amit Pande
Dept. of Surgery, Era’s Lucknow Medical College, Sarfarazganj, Lucknow, UP, India. PIN-226003. drarijitroy7@gmail.com
INTRODUCTION
The gastrointestinal (GI) tract is the 6th most common site involved in tuberculosis. Perforation is an uncommon complication of abdominal TB- most commonly in terminal ileum. Lesions affecting the peritoneum as well as small and large bowel presenting with perforation of transverse colon with fecal peritonitis as the presenting feature is exceptional. Abdominal tuberculosis presenting as diffuse peritoneal carcinimatosis is a very rare occurrence.
AIMS/OBJECTIVE
To present a rare case where disseminated abdominal abdominal tuberculosis mimicked diffuse peritoneal carcinomatosis on laparotomy.
CASE REPORT
A 38 year old male patient presented with pain abdomen for 3 months, obstipation and vomiting for 3 days. No history of fever, night sweats. Perforation peritonitis was confirmed and emergency laparotomy was done. Multiple whitish nodules of varying sizes (5 mm–3 cm in diameter) were found studded on the omentum, anti-mesenteric border of the bowel and mesentery. A perforation of 0.5 cm D was found in transverse colon about 10 cm proximal to the splenic flexure, which was primarily closed with non absorbable sutures. Protective ileostomy was created. Peritoneal carcinomatosis was suspected per-operatively. However, no primary lesion could be identified. Biopsy was taken and nodules from small bowel, omentum and peritoneum were sent separately for histopathological examination. The histopathology of the resected nodules showed large extensive areas of caseous necrosis bordered by epitheloid cells, scattred Langhan’s type giant cells and lymphocytes suggestive of tubercular pathology.
CONCLUSION
Abdominal tuberculosis presenting as perforation peritonitis with large nodular tubercles present all over the abdomen mimicking peritoneal carcinomatosis with perforation in transverse colon is the rarest form of presentation.
22) LARYNGEAL CHONDROSARCOMA—A CASE REPORT
AUTHORS Tapaswini Pradhan*, Ashish Goel*, Anoop Puri*, Sandeep Mehta**, A K Dewan*
SURGICAL ONCOLOGY*, RECONSTRUCTIVE SURGERY**
Rajiv Gandhi Cancer Institute, Delhi. anooppuri4u@yahoo.com
INTRODUCTION
Chondrosarcoma of larynx, accounts for less than 0.2% of all head neck malignancies, & 0.07–2% of all laryngeal cancers. Peak incidence is in 6th to 7th decade. 75% of these tumors originate in endolaryngeal surface of posterior lamina of cricoid cartilage, 15% originate from thyroid cartilage and the rest from arytenoids. Most common presentation is hoarseness due to crico-arytenoid joint involvement.
CASE REPORT
We present a 56 year old gentleman presenting with hoarseness for last two years and swelling corresponding to the right thyroid lobe for 6 months and recent onset exertional dyspnea. Direct Laryngoscopy revealed smooth mucosal bulge of the right false and true cord with right vocal cord palsy. CT Guided biopsy showed cartilage forming tumour, with nuclear morphology favoring benign pathology. MRI showed Laryngeal framework involvement. The patient underwent total laryngectomy with partial pharyngectomy with right hemithyroidectomy. Final Histopathology suggested grade II Chondrosarcoma, for which he received adjuvant radiation therapy.
CONCLUSION
Due to their slow growth and low metastatic potential, the initial management should be surgical resection partial or total laryngectomy. Despite recurrences, these tumors can be salvaged with a considerably high success rate. The role of radiotherapy in the primary or in the adjuvant setting and also the use of chemotherapy have been a matter of debate, but till date, is considered to be ineffective.
23) Jejunal adenocarcinoma: a case report
Amit Kishore*, AshutoshChauhan**, Mala Mathur**,SanjayKapoor#, AtoshiBasu+
Dept of Surgical Oncology* &Dept of Pathology+. Command Hospital (CC) Lucknow. amity_solemn81@yahoo.co.in
23 year old lady presented with dull aching pain upper abdomen. anorexia and weight loss for 3 months.On examination found to have hard, nodular, nontender, intraperitoneal lump of size 12 cm × 10 cm in left upper quadrant.Transversely Mobile
CECT abdomen: circumferential thickening of proximal jejunum, extensive retroperinoneal lymphadenopathy.
Intra op : mass of size10 × 10 cms arising from proximal jejunumjust distal to DJ flexure . Extensive retroperitoneal lymphnode mass. Tumor was found to be unresectable.Biopsy was taken. Feeding jejunostomy done in view of poor nutritional status of patient.
HPR: mucin secreting moderately differentiated Adenocarcinoma
Patient planned for chemotherapy.
24) Surgery for Primary Tracheal Tumors; Twenty four Cases and 6 years later
S Bal, R Kumar, P Srikhande**, RK Mani*
Department of Thoracic Surgery & Thoracic Surgical Oncology, Pulmonology* and Critical Care, Fortis-Escorts Hospitals , Delhi & NCR. drsbal@gmail.com
Keywords : Primary tracheal tumours
Introduction : Primary tracheal cancers are uncommon but important entity because of the role of surgery and the curability of the condition, if recognised early. The surgery is considered risky with major morbidity and definite mortality.
Aims and Objectives : To analyse the results and techniques of our experience with these tumours from 2005–2010
Methods and Results : Between 2005 and 2010, 24 primary tracheal tumours were sen by a single Thoracic Surgical team.The most common was the epidermoid carcinoma (14) followed by adenoid cystic carcinoma (9). One schwannoma of primary tracheal origin was seen. An early clue to the diagnosis is the flow volume loop.
All patients were operated and underwent tracheal resection and anastomosis. The incision was different for different locations of the tumour and a CT reconstruction helped immensely as a road map.
Serious morbidity occured in 2 patients but there were no deaths. Radiotherapy was given to 8 patients. Follow up is available for 9–65 months.
Despite all known risks, the most appropriate type of treatment for primary tracheal tumors is surgery and can be done with good results.
25) 1. TITLE—Extragonadal Retroperitoneal Seminoma with “Burned Out” Phenomenon in the Testis—a case report.
2. AUTHORS
i) PRADYUMNA KUMAR SAHOO
ii) SUPTI MUKHOPADHYAY
iii) PALASH MONDAL
iv) SAMINDRA NATH BASAK
NAME OF INSTITUTE—CANCER CENTRE WELFARE HOME AND RESEARCH INSTITUTE, KOLKATA, WEST BENGAL. pradyumnakumar@rediffmail.com
KEY WORDS: Testis, Retroperitoneal Seminoma, Germ Cell Tumor
ABSTRACT
Retroperitoneal seminoma without involvement of the testis is very rare. Germ cell tumor is the most common malignancy in men aged 15–35 years. Five percent of the malignant germ cell tumors (GCT) are extragonadal in origin. Here we present a case of retroperitoneal seminoma which presented with pain in abdomen and back, diagnosed as retroperitoneal seminoma after trucut biopsy and IHC. The ultrasonography showed a lesion in left testis. High inguinal orchidectomy was done and histopathology reported as fibrosis only without any tumor i.e. burned out phenomenon. A laparotomy biopsy was taken and also reported as retroperitoneal seminoma. Re-grossing of orchidectomy specimen reported the same. The patient is on chemotherapy treatment.
26) RARE CASES OF SOFT TISSUE SARCOMAS—ANGIOSARCOMAS OF SCALP AND BACK
AUTHOR: DR. VIKAS SINGH, DR. B. K. CHATTOPADHYAY, DR. D.K. SARKAR
INSTITUTION: IPGMER & SSKM HOSPITAL, KOLKATA. piyush0031@yahoo.com
Angisarcomas are rare vascular tumors, the cells of which manifest many of the morphologic andfunctional properties of normal epithelium. Although angiosarcomas may occur in any location ,they ar particularly found in head and neck region and they rarely arises from major vessels.
Generally radical surgery and postoperative radiotherapy are advocated to treat patients with these tumors. Achieving a negative surgical margin is frequently difficult in patients with scalp angiosarcomas because of the extensive microscopic spread common with this disease.
This poster deals with cases of angiosarcomas and principles of their management and follow up results of these patients in details.
27) Title: Gastrointestinal stromal tumour (GIST)—Report of 4 cases
Authors: Dr. Jaipalreddy, Prof. Sanjeev Misra, Dr. Vijay Kumar
Institute: Chatrapati Shahuji Maharaj Medical University (CSMMU), Lucknow. jaipalreddy.pogal@gmail.com
Introduction: GIST have recently been subject of considerable clinical interest because of identification of their activating signal (c-kit) and development of a therapeutic agent that suppresses tumour growth by inhibiting this signal (imatinib mesylate). Diagnosis of these tumors is difficult to establish, because symptoms are vague and traditional diagnostic tests are not specific. GISTs show a wide variety of clinical behaviors ranging from benign to frankly malignant, making the outcome totally unpredictable.
Case Summary: The present report describes four patients with diagnosis of GIST.
Case1: Case of small bowel GIST who underwent wide local excision with reanastomosis. He was asymptomatic for 7 years and then developed solitary liver metastasis which was resected. He was asymptomatic for 2 years then developed recurrent lesion in liver and scalp. He is now on imatinib treatment with stable disease.
Case2: Case of GIST of stomach presented with huge epigastric mass abutting left lobe liver. Due to advanced nature of disease the patient was not considered for surgery and was started on imatinib. He has good response with tumour shrinking and free planes with liver on follow up.
Case3: Case of Duodenal GIST who presented with history of malena since 3 months. On upper GI endoscopy there was a polypoidal mass on posterior wall of 2nd part of duodenum. He underwent exploratory laparotomy, had localized disease in 2nd part of duodenum. He underwent wide local excision with primary excision. He is on regular follow up.
Case4: Case of GIST of small bowel operated (resection and anastomosis). He was asymptomatic for 4 years. He then presented to with moderate abdominal distention. CT Scan revealed recurrent mass in left flank. Ascitic fluid cytology was positive for malignant cells. He has been started on imatinib and is having good response.
Discussion: Gastrointestinal Stromal Tumours (GIST) though are rare malignancies, are the most common mesenchymal tumours of gastrointestinal tract. Initially managed as surgical disease with relatively poor prognosis, a greater understanding of GIST pathobiology has transformed therapeutic options and led to an improved prognosis with advanced disease. The recent availability of an effective systemic therapy raises issue of its potential use as adjuvant or neoadjuvant treatment in conjuction with surgery with objective of either cytoreduction of disease before surgery or improvement in long term survival after successful resection.
Key words: Gastrointestinal Stromal Tumours (GIST), c-kit, Imatinib
28) TITLE BASAL CELL CARCINOMA OF THE LOWER LIMB—A RARE PRESENTATION.
AUTHOR: Prof. Osman Musa, Dr, Jagadamba Sharan, Dr. Arijit Roy, Dr.Amit Pande (Presenter)
Dept. of Surgery, Era’s Lucknow Medical College, Sarfarazganj, Lucknow, UP, India. PIN-226003. ph—9956649017 ; drarijitroy7@gmail.com
INTRODUCTION
Basal cell carcinoma usually occurs in the upper part of the face especially near the outer canthus of the eye and in sun exposed areas; more in fair skinned individuals and Caucasian races. Basal cell carcinoma (BCC) in the lower limb in an Indian patient is a very rare occurrence.
AIMS/OBJECTIVE
To present a rare case of non healing ulcer in the popliteal fossa of a 27 year old man which turned out to be basal cell carcinoma.
CASE REPORT
A 27 year old male patient presented with a non healing ulcer in the popliteal fossa for the last 12 years. He tried various treatments from local practitioners, involving debridements, dressings and partial excisions; but the ulcer refused to heal. A wedge biopsy confirmed it to be here BCC. A three dimensional wide excision of the ulcer was done with a 2 cm healthy margin. Primary closure was done and the wound healed well. There was no recurrence after a 1 year followup.
CONCLUSION
Basal cell carcinoma occurring in the lower limb of a person of Indian origin is a very rare entity.
29) Title: Second primaries in cancer survivors treated at a tertiary care centre—possibility of an unknown etiology.
Authors : Kannan N, Kulshreshtha Pranjal, Takkar P, Sanchety N, Batra Swati. .
Institute: Army Hospital (Research & Referral), Delhi Cantt, Delhi-10. pranjal7088@gmail.com
Key words: synchronous, metachronous, cancer survivors
Introduction: In the past 3 decades, the number of cancer survivors has tripled, reaching approximately 10.7 million in 2004. Subsequent malignancies among this high-risk group account for about 16% (or 1 in 6) of all cancer incidences. Multiple primary cancers can be grouped into three major categories according to predominant etiologic influences (i.e., treatment-related, syndromic, and those due to shared etiologic factors). Aims & Objectives: The present study was conducted to evaluate the incidence of second primaries in long term cancer survivors treated at our hospital. Methods & Materials: The study was conducted by retrospective analysis of records of all patients treated at our Hospital in the past 5 years, with identification of patients developing multiple primaries. Detailed epidemiological data was thereafter collected for these patients with particular reference to risk factors and outcome. Results: 28 patients were identified in the last 5 years with a total of 57 malignancies. Bilateral breast tumors were the most common (5/28 patients), followed by gallbladder with ovarian cancer (2/28), rest all being solitary combinations. Breast cancer was the most common malignancy (present in 12 patients), followed by ovary (5), HNSCC (5) and colon (4). Although genetic testing was not available for any patient, 5 patients fell into possible syndromes. 7 patients had possible shared etiology as the cause of the multiple primaries, while none appeared to have therapy related cancers. Thus, 16 patients were left with no possible etiology. Conclusion—Second primaries in cancer patients are an important and not so uncommon entity, which should be actively ruled out in the face of findings before labelling them as metastatic. The etio-pathogenesis of the majority of these cancers does not fall into known causes and further research is required for the same.
30) Title—Tracheal Injury: Surgical management
Authors: Kannan N, Gupta S.
Institute: Army Hospital (Research & Referral), Delhi Cantt, Delhi. majkannan@gmail.com
Command Hospiatal Western Command Chandimandir
Keywords: tracheal injury, intercostals flap repair, iatrogenic
Introduction: Tracheal injuries are uncommon, are often reported during surgical procedures for lung and esophageal cancers and portend a poor outlook. Aims & Objectives: We report 4 cases of tracheal injury incurred during surgery for esophageal cancer and their successful management. Methods and Materials: The data was collected prospectively for all patients incurring tracheal tears during esophageal cancer surgeries being done at this centre over the past 6 years. Results: We encountered 4 cases of tracheal tear occurring over 6 years during surgery for carcinoma esophagus cases. One was a dissection injury during transhiatal dissection of the esophagus, the remaining 3 being due to overinflation of the endotracheal tube cuff. All injuries were identified peroperatively by subcutaneous or mediastinal emphysema, or sudden loss of airway control. All injuries were repaired by direct suturing of the membranous trachea and reinforcement by a vascularised intercostal muscle flap, with uneventful postoperative recovery. Discussion: Tracheal injury is an uncommon event, usually resulting from direct tracheal invasion by the disease, intubation injuries being rarer still. The posterior tracheal wall is thin and membranous and needs reinforcement by muscle, pleura or pericardium for effective healing. Conclusion:Tracheal injury during esophageal surgery is a rare entity, requiring expedient and expert management. Outcome is largely dependant on surgeons’ expertise and familiarity with the situation.
31) Title—Isolated metachronous colonic metastasis from squamous carcinoma of the uterine cervix—A case report
Authors—Kannan N, Batra Swati, Takkar P, Sanchety N.,
Kulshreshtha Pranjal Institute—Army Hospital (Research & Referral), Delhi Cantt, Delhi. majkannan@gmail.com
Keywords—squamous, cervical cancer, colonic metastasis
Introduction: Distant metastases from squamous carcinoma of the uterine cervix have been reported to occur in 9–27% of patients treated by radiation. The colon is an extremely unusual site of metastasis, in particular as the solitary site of metastatic spread, with only 7 cases reported so far. Such solitary metastatic disease maybe synchronous or metachronous, with the latter portending a better prognosis. Case Report: We report a case of a 50-year-old lady who presented to us 1 year after having been inappropriately treated with an extrafascial hysterectomy+bilateral salpingo-oophorectomy for perimenopausal metrorrhagia at a peripheral hospital with a post-operative histopathological diagnosis of FIGO 1B squamous carcinoma of the cervix. On staging evaluation at our centre, she was detected to have a residual/recurrent vault mass infiltrating into the parametrium (rT3a) and a discontiguous transmural growth in the sigmoid colon, biopsy of which was reported as poorly differentiated carcinoma. She was managed with a radical sigmoid colectomy, the histopathology of which revealed a transmural squamous cell carcinoma involving the sigmoid with negative nodes and no other e/o peritoneal disease. The patient is being subsequently managed with chemotherapy. Conclusion: Isolated colonic metastasis from cervical carcinoma is a rare but known entity, differentiation of which from a second primary is difficult and necessary. Intent to treat such patients has to be weighed in terms of other factors before condemning them to palliation.
32) TITLE: AN ATYPICAL RECTAL MASS—RECTAL GIST (POSTER)
AUTHOR: DR SYED HASSANUJJAMAN
drhasancmc@gmail.com
INSTITUTE: I.P.G.M.E & R , S.S.K.M. HOSPITAL, KOLKATA
CASE CAPSULE: A 60 year old man presenting with urinay complaint, p/r exam reaveled smooth anterior wall rectal mass, MRI—submucosal lesion.Peranal wide local excision done.HPE –GIST, CD 117 + .
33) Triple negative breast cancer
Dr Poornima,Prof Krishnamurthy, Dr Ravi arjun,DR vasu Reddy, DR Basavanna Goud
Kidwai memorial Institute of Oncology. poornima.r192@rediffmail.com
KEY words—Triple negative, CnS Metastasis,recurrence
Triple Negative Breast Cancer is an Immunohistochemically defined subtype with significant diversity with in the subtype Little is known about the etiologic profile of triple negative breast cancer (which is negative for oestrogen eceptors/progesteron receptors/human epidermal growth factors)a breast cancer sub type that generally occur in younger women and is marked by high rates of relapse,visceral and CNS metastasis and early death
We Retrospectively studied 50 cases of TNBC who presented in our OPD over 1 year and analysed tumor characteristics (morphology, grade and size, ER/PR and Her2 expression), recurrence, date and cause of death, and length of survival
Our study showed that TNBC has poor over all and disease free survival IHC classification provides both Therapeutic and prognostic information
Our observations suggest that triple negativity can significantly affect progression of breast cancer in Indian breast cancer patients and longer follow up is necessary (10 years) to determine its effects on survival.
34) Title : Adrenal Myelolipoma—A management dilemma
Article Type : Poster presentation
Author : Pradeep Jaiswal, MBBS,MS (gen surg) , DNB (onco surg)
N K Saida , MBBS,MS (gen surg) , DNB (onco surg)
Institution : Command Hospital Air force Bangalore. drjaiswalpradeep@yahoo.co.in
Keywords : Adrenal myelolipoma; incidental; conservative management
Abstract: Adrenal myelolipoma is a rare, benign, mostly non functional tumor of adrenal gland. It is mostly often picked up as incidental finding on scans for vague abdominal symptoms .Radiological investigations are diagnostic for the condition. While observation is recommended for smaller lesions,opinion is divided regarding management of larger lesions .Larger myelolipoma are often associated with pain and can have spontaneous haemorrhage. A case report of middle aged male presenting with incidentally detected Adrenal Myelolipoma on investigation for vague symptoms treated at our center is presented in the poster with review of relevant literature.
35) TITLE: PERFORATED JEJUNAL GIST PRESENTING AS ACUTE ABDOMEN: A RARE CASE REPORT.
Authors: Vinay kumar J R, Giri S K, Mohanty R K, Debata P K.
Institute: S C B Medical college, Cuttack, Orissa. jrvk85@gmail.com
Key words: Acute abdomen , perforation , gastrointestinal stromal tumors (GISTs) , imatinib, CD117. CD 34.
Introduction: GISTs are the most common mesenchymal tumour of the gastrointestinal tract. GIST can arise any where along the GI tract, but stomach(60%) and small intestine(30%) are the most common primary sites. Among the small intestinal GISTs , Duodenum is most common site and jejunal GISTs are extremely rare. GISTs are characterized with diverse clinical presentations, including abdominal pain, presence of an intra-abdominal mass, anorexia, intestinal obstruction, acute and chronic gastrointestinal bleeding. Various unusual presentations of GIST have been described, including spontaneous rupture leading to acute abdomen. Here we present a case of perforated jejunal GIST presenting as acute abdomen.
Case report: A 65 years old male patient visited to our emergency department with generalised abdominal pain, vomiting. An emergency laparotomy revealed a ruptured jejunal tumour with bloody fluid in the peritoneal cavity. The perforated part along with the tumour was resected and ent to end enteroenterostomy done. The cytopathological examination showed that the tumor was GIST. Immunohistochemistry of tumour cells was strongly positive for CD34 and CD117. Postoperatively, the patient received adjuvant therapy with imatinib.
Conclusion: GISTs are characterized with diverse clinical presentations, including rare presentations like acute abdomen due to perforation and haemoperitoneum. So these rare presentations should be kept in mind for better management of GIST in emergency settings.
The optimal care of patients with GIST in the current era demands a multidisciplinary approach. For patients presenting with localized resectable disease, complete surgical resection of the tumour remains the primary therapy, but drug therapy is being considered in the adjuvant or neoadjuvant settings. While patients with non-localized disease largely benefit from systemic drug therapy, surgical resection continues to play an adjunctive or salvage role. Palliative debulking of GISTs may be indicated for patients with tumor perforation or hemorrhage, or in those who are poor risk surgical candidates.
36) TITLE: CARCINOMA BREAST PRESENTING AS ABSCESS: CASE REPORT AND REVIEW OF LITERATURE
Name of the Author: VINAY KUMAR J R
jrvk85@gmail.com
INTRODUCTION: Inflammatory carcinoma of breast , a rare condition most commonly seen in lactating women presents with signs of acute inflammation and behaves aggressively. But adenocarcinoma of breast presenting as localised abscess is not known. We came across two patients who were initially treated for abscess but later diagnosed as adenocarcinoma.
CASE REPORT: First case: 45 yrs old post menopausal female presented with painful swelling in upper outer quadrant of the right breast of size 3*2 cms , which was tender and fluctuant. The skin over the swelling was red . There was no axillary lymphadenopathy. 10 ml of frank pus was aspirated and patient was treated with antibiotics. But after 10 days, swelling reappeared. Incision and drainage done under general anaesthesia. Intraoperatively we found induration in the base of abscess cavity, biopsy was taken from the base. Histopathology revealed adenocarcinoma. The patient underwent modified radical mastectomy. Now the patient is on adjuvant chemotherapy and hormonal therapy.
Second case: 33 years old female presented with painful swelling in the areola of right breast which was tender. Periductal mastitis was diagnosed and pus was aspirated. Patient received one course of antibiotic. As the swelling reappeared, ultrasound of right breast was done. It revealed hypoechogenic mass with irregular margin and microcalcification suggestive of carcinoma. Ultrasound guided core needle biopsy confirmed adenocarcinoma. The patient undergone modified radical mastectomy with adjuvant therapy.
DISCUSSION: Review of literature revealed , there were many cases of pure squamous cell carcinoma and metaplastic carcinoma of breast presenting as breast abscess . But only two cases of adenocarcinoma of breast presenting as abscess were reported; in 58 years old diabetic woman and 42 years old man. Pathophysiology of breast carcinoma presenting as abscess is not known may be secondary to necrosis of tumour. Breast abscess in nonlactating and postmenopausal women, especially recurrence after aspiration and antibiotic treatment should be thoroughly investigated by imaging modalities to exclude malignancy.
CONCLUSION: Breast abscess which is benign lesion can harbour the malignancy in it. Recurrence of breast abscess after conventional treatment especially in non lactating and post menopausal women requires thorough evaluation to exclude carcinoma.
37) TITLE :WHO IS REPONSIBLE FOR DELAY ?
AUTHOR : Dr. Prashant S Patil, Dr.Diptendra K Sarkar
Hospital : SSKMHOSPITAL,/IPGME & R, KOLKATA. docprashant2010@gmail.com
Introduction: For cancer patients to have any chance of good outcome,early diagnosis & timely treatment is extremely important. Primary physician whom the patient consults first is probably the vital link in health chain .We conducted a study to find out the reason for delay in the treatment of patient,for advanced stage presentation of patient and steps we can take to change this.
Aims :1)To find out mean time between first symptoms of patients and first visit to a physician 2)To know about patient’s own idea about his illness 3)To find reason behind late stage presentation
Methods :We interviewed 387 patients presenting to surgery OPD between Jan-2010 to Jan 2011 .Patients were randomly selected for the study.Study group comprised of cancer patients only.We assessed patient’s knowledge about his illness,the duration of symptoms before presentation,the advice/treatment patient received at his/her first visit to physician,further treatment he/she received at referral centre.We included patients of breast,thyroid,anorectal malignancy and soft tissue sarcoma in our study.
Results :We found that about 70% of patients were concerned about their illness and presented in time for treatment.However ,in many cases,they receieved either no treatment or got wrong advice/treatment by primary physician who misdiagnosed or at times performed wrong surgical procedure.
Conclusions : Patient usually presents in time with classical symptoms in many cases & are concerned about their illness and have some idea about the seriousness of disease. Wrong diagnosis,incorrect treatment or neglect of symptoms of patient by primary physician is responsible for ultimate poor outcome of many patients.
Discussion : We need to increase awareness among physicians as well as patients about signs and symptoms of malignancy.
38) Title : Immediate Oncological and Cosmetic outcomes of oncoplastic breast surgery in India : an initial report.
Authors : Dr. S. Veda padma priya Selvakumar, Dr. Shuaib Zaidi, Dr. Pankaj Pande, Dr. Sandeep Mehta, Dr. Kapil Kumar
Hospital: Rajiv Gandhi Cancer Institute & Research Centre. privedsri@gmail.com
Keywords : Oncoplastic breast surgery
Background: Oncoplastic breast surgery is a novel concept and innovative techniques in breast conserving reconstruction has enhanced aesthetic outcome without compromising on the oncological control. In this background we sought to analyse the immediate outcomes(both oncological and aesthetic) after oncoplastic breast conserving surgery in a tertiary cancer centre in india. Materials & Methods : We retrospectively reviewed the records of patients who underwent oncoplastic breast surgery from April 2010 to October 2010 at RGCI & RC. The various parameters such as age at presentation, Tumour characteristics (size,location,histology), tumour breast ratio, MR Mammographic features, Type of oncoplastic technique, Status of resected margins, aesthetic outcome were analysed. Results : The total number of patients who underwent Oncoplastic breast surgery for carcinoma breast between April and October 2010 were 16. Median age of presentation was 47. Right : Left ratio was 6:10.Stage distribution was stage I : 3 ; II : 10 ; III : 2 ; IV : 1. The mean of clinical tumor volume estimated by MRI was 21.7988 cc. Seven of them underwent reconstruction by volume displacement techniques while nine of them underwent reconstruction by volume replacement techniques. Mean margin of resection was 1.09 cm. The mean specimen volume was 483.756 cc. All of them are disease free with a median follow up was 9 months. Conclusions :The use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority of patients.
39) TITLE—AN UNUSUAL PRESENTATION OF PANCREATIC NEOPLASM
AUTHOR’S NAME—Dr. Amit sinha under guidance of Dr. Bitan kumar Chattopadhyay & Dr. Diptendra kumar Sarkar
INSTITUTE- IPGME&R & SSKM Hospital, Kolkata. babai8523@yahoo.in
KEY WORDS—lymphoma may invade pancreas
INTRODUCTION—Primary pancreatic lymphoma is rare, comprising 0.2-4.9% of all pancreatic malignancies and less than 1% of cases of non-Hodgkin’s lymphoma
AIMS &OBJECTIVES-To find out different mode of presentation of pancreatic neoplasm
To specify its treatment modality
METHODS- History and investigations of patient
RESULTS- Etiology found out and adequate treatment given
CONCLUSION- lymphomasNon-Hodgkin lymphoma predominantly involving the pancreas is a rare tumor and accounts for less than 0.7% of all pancreatic malignancies and 1% of extranodal
DISCUSSION-
40) Title—Squamous cell carcinoma of unusual sites: case reports of one in gall bladder and one in kidney
Authors: Kannan N, Pranjal Kulshreshtha, Takkar P, Sanchety N, Batra S
Institute: Army Hospital (Research & Referral), Delhi Cantt, Delhi. pranjal7088@gmail.com
Keywords: squamous cell cancer, gall bladder, kidney
Introduction: Squamous cell carcinoma of the gall bladder is present in 0–3.3% of all GB cancers and is more aggressive than adenocarcinomas. SCC of the kidney accounts for 1.4% of all renal malignancies. Surgery is the mainstay if diagnosed at a resectable stage. Case Report 1: 65 year old female diagnosed with a GB mass underwent exploration at another hospital and simple cholecystectomy (due to adhesions), found to have pure keratinizing SCC (pT1bN0). Underwent completion Radical cholecystectomy at our hospital, found to have liver parenchyma involvement on histopathology. Treated further with adjuvant chemoradiation. Presently disease free. Case report 2: 70 year old female with weight loss, detected to have left renal lump. Underwent left radical nephrectomy with retroperitoneal lymph node dissection and found to have pure keratinizing SCC of the renal parenchyma (T4) with nodal deposits (N2). Also had incidentally detected DCIS of the right breast, treated by wide local excision and tamoxifen. Currently disease free. Conclusion: SCCs of the gall bladder and kidney are a rare entity with a more aggressive behaviour and poorer prognosis, requiring aggressive multimodality therapy, although surgery remains the mainstay.
41) Title: TRANS HIATAL OESOPHAGETOMY FOR A PATIENT WITH CARCINOMA OESOPHAGUS WITH SITUS INVERSES TOTALIS—A CASE REPORT
Authors: 1. Prof Dr Rajaraman Ramamurthy, MS., M Ch,
2. Dr Subbiah Shanmugam, M.S, M Ch,
3. Dr Sujay Susikar, M Ch Postgraduate student
Hospital / Institute: Department of Surgical Oncology, Government Royapettah Hospital and Kilpauk Medical College, Chennai. sujaysusikar@gmail.com ABSTRACT:
A case of carcinoma of lower 1/3rd oesophagus with situs inverses totalis, presented with dysphagia. She was investigated clinically and endoscopically and found to have circumferential growth at the lower 1/3rd of the oesophagus extending in to the OG junction. Biopsy of the lesion revealed to be squamous cell carcinoma. On further evaluation with CT-scan for metastatic work up we identified the malposition of the visceral organs. There was no perioesophageal disease, no major vascular invasion or distant metastasis. So a Transhiatal oesophagectomy was done. The combination of situs inverses totalis with carcinoma oesophagus of lower 1/3rd extending in to the OG junction is a rare entity and further more, to perform surgery for these patients requires precise anatomical knowledge, awareness of the anomalies, and a meticulous surgical technique for a sucessesful outcome. So the present case is a combination of all rarities.
42) Title—Gingival metastasis from carcinoma breast.
Authors—Dr. Sameer Gupta, Prof. Sanjeev Misra, Dr. Vijay Kumar, Prof. Nuzhat Husain
Institute—Chatrapati Shahuji Maharaj Medical University (CSMMU), Lucknow. sameerdr79@gmail.com
Introduction—Metastatic tumors to the oral region com¬prise only 1%–3% of all malignant oral neoplasms.. Metastatic lesions may occur in the oral soft tissues, in the jawbones or both. The common primary sources of tumors metastatic to the oral region are the breast, lung and kidney. The lung is the most common source of metastases to the oral soft tissues, whereas the breast is the most common source for metastasis to the jawbones.
Case summary—52 year old female presented 8 years ago with locally advanced carcinoma of right breast (T4N1M0). Metastatic workup was normal. Patient received 2 NACT with cyclophosphamide, doxorubicin and 5-Fluorouracil (CAF) followed by modified radical mastectomy. Her histopathology revealed infiltrating duct carcinoma NOS, pT2N1M0.Post surgery she received 5 cycles adjuvant chemotherapy with CAF but defaulted on adjuvant radiotherapy. She received adjuvant Tamoxifen for 5 years. She was disease free for 5 years. She then presented with right supraclavicular lymph node recurrence and sternal metastasis. She was treated with chemotherapy with complete response. After asymptomatic period of 3 years,she presented with massive hepatomegaly with multiple liver metastasis and 4 × 3 cms soft tissue mass in right gingivobuccal sulcus, with no underlying mandible erosion. A possibilty of metastasis from breast cancer was kept and an incisional biopsy confirmed metastasis from ductal carcinoma breast after which patient was started on injection paclitaxel based chemotherapy with 80% response in the oral metastasis.
Discussion—90% of metastases in oral cavity are located in either the mandible or the maxilla, and only 10% involve the soft tissues of the oral cavity with adenocarcinoma being the most common histologic type. Breast adenocarcinoma is the most common female malignancy that metastasizes to the mandible or maxilla, but breast cancer metastasis to the soft tissues of the oral cavity is extremely rare.
Key words—Carcinoma breast, metastasis, oral cavity.
43) EVALUATION OF AXILLARY LYMPH NODAL METASTASES IN BREAST CANCER PATIENTS BY DUPLEX SONOGRAPHY
AUTHOR: DR. VIKAS SINGH, DR. B. K. CHATTOPADHYAY, DR. D.K. SARKAR
INSTITUTE: IPGMER & SSKM HOSPITAL, KOLKATA. piyush0031@yahoo.com
INTRODUCTION
At present we have 3 methods of axillary evaluation viz, axillary lymph node dissection, sentinel lymph node biopsy and ultrsonographic evaluation. This study search for the increased role of duplex sonography
AIMS AND OBJECTIVES
To evaluate the accuracy of Duplex ultrasonography in the pre-operative diagnosis of metastatic invasion of the axilla in patients with breast cancer
Avoid unnecessary axillary dissection
METHODS:
INCLUSION CRITERIA EXCLUSION CRITERIA
patients with histopathologicaly proven cases of breast ca posted for surgery patients not willing to be part of study
¬ Diagnosed cases of breast cancer underwent USG examination of bilateral axilla
¬ Lymph nodes visible by ultrasonography categorised into benign or malignant.
CONCLUSION:
On going trial
Duplex sonography shows promise in detection of axillary lymph nodal metastases
In India with a large Breast cancer burden and limited resources—it can be MOST COST EFFECTIVE method of evaluation of Axilla.
44) High Bifurcation of Common Carotid artery with anomalous origin of Superior Thyroid artery
Authors: Preeti Jain, Anjaneya Dube, Gaurav Agrawal, Tanveer A Majeed Satyam Taneja, B B Pandey, J K Singh.
preetijain30@gmail.com
Key Words: Common Carotid Artery, Superior thyroid artery, common carotid artery bifurcation.
INTRODUCTION:
Variations in the bifurcation of common carotid artery(CCA) and the origin of superior thyroid artery are documented. We report a case of high bifurcation of CCA with the origin of Superior Thyroid Artery (STA) from CCA unusually proximal to the bifurcation.
CASE REPORT:
A 45 year old male patient presented with a large Ameloblastoma of mandible which required a hemimandibulectomy. Intra operatively, the left CCA was found to divide into ECA and ICA in the digastric triangle. The origin of STA was 2.5 cm inferior to the carotid bulb. The hypoglossal nerve was found running superficial to both ECA and ICA.
DISCUSSION:
Variations of the CCA include its absence, high or low bifurcation and also its abnormal branches.
Kitagawa gave the incidence of the STA arising from the CCA as being 11.7% on the right and 26.5% on the left in the autopsies of 37 Japanese fetuses. In a report by Akyol et al from Turkey, in over 200 neck dissections performed, in only 2 (1%) cases was STA noted to originate from the CCA.
Variations in the origin of the STA could have important surgical repercussions. The most important being the emergency ECA ligation for acute hemorrhage in head and neck region. The accepted site of ECA ligation is superior to the origin of the STA to ensure its identification and to prevent embolism into ICA.
CONCLUSION:
Our case shows, that the level of bifurcation of CCA and the origin of STA can vary. STA may not be a reliable landmark for the identification of ECA and to identify a safe point for its ligation. The only reliable method to identify ECA is identification of more than two branches, and preferably a clear identification of ECA and ICA separately.
45) PSEUDO PAPILLARY NEOPLASM OF THE PANCREAS : AN EVOLVING NEW ENTITY .-
AN IPGMER & SSKM HOSPITAL, KOLKATA EXPERIENCE bhargav.chikkala@gmail.com
Dr. Bitan Kumar Chatopadhay, Dr. Diptendra Kumar Sarkar
IPGMER & SSKM HOSPITAL.
Key Words: cystic neoplasms , pancreas , solid pseudo papillary tumor
INTRODUCTION :
Cystic neoplasms of the pancreas have long posed diagnostic and treatment dilemmas. They contribute to about 10% of the cystic lesions of the pancreas . There seems to an increase in the diagnosis of these neoplasms probably due to the advances in the diagnostic modalities .the solid pseudopapillary tumor is a rare type of a cystic neoplasm. There seems to be a significant rise in the frequency of this entity in our patients of cystic neoplasms of the pancreas.
AIMS AND OBJECTIVES :
The aim of this study is to establish the rising frequency of the solid pseudopapillary neoplasm and to delineate the incidence , diagnostic criteria and their management
MATERIALS & METHODS :
This is a combined , retrospective and prospective study from the patients who were clinico radiologically diagnosed to have a cystic neoplasm of the pancreas .These patients have been followed up intra and post operatively , and the histopathological reports of these patients have been evaluated , to check their disease sub type and its frequency in our patient group and the correlation of their pre operative clinico radiological diagnosis and their histological subtype and also the response to the treatment offered.
RESULTS :
Out of the 22 patients , who have been diagnosed to have a cystic neoplasm of the pancreas , 9(41%) have been diagnosed to have a solid pseudopapillary tumor .
.Age : 7/9(77.7%)patients were in the age group of 25–29 years
. Sex : 8/9(88.8%) were females
. most common symptom—7/9(77.7%) dull aching pain in the epigastrium , and 2/9 were diagnosed incidentally. Radiological diagnosis : 2/9 (22.2%) were diagnosed as mucinous variety , 6/9 (66%) were diagnosed as a serous variety and therest 1/9 (11.1%) were inconclusive.
Most common site of involvement—tail of the pancreas 8/9 88%
0/9 were from the body of the pancreas.
1/9 ( 11.1%) was from the head of the pancreas.
.one patient was inoperable
.one death related to the post operative complications
.one patient lost follow up.
CONCLUSION:
There is an increased incidence of the diagnosed cases of the cystic neoplasms of the pancreas probably due to an increase in the superiority of the investigations.
The solid pseudopapillary is no more a rare entity as was described , and that there is a rise in the incidence of these neoplasms specially the young age group , optimally treated and having a good prognosis .
Surgical resection of these tumors has a good prognostic outcome.
Discussion :
cystic neoplasms of the pancreas though were said to be rare, now are being diagnosed more commonly, probably due to an increased and readily available radiological investigations .However, the pre operative diagnosis based on the radiological investigations may not correlate with the post operative histopathology, thus making a conservative approach in possible benign cases costing both the patient and the doctor. These tumors, carry an excellent prognosis when operated early and treated appropriately .
46) TITLE : ROBOTIC RADICAL HYSTERECTOMY FOR CERVICAL CANCER : AN INITIAL STUDY
Authors: VEDA PADMA PRIYA.S(Presentor), AMITA MISHRA,SHVETA GIRI, RUPINDER SEKHON, SUDHIR RAWAL.
Institute: Rajiv Gandhi Cancer Institute,Delhi. privedsri@gmail.com
Objectives : To evaluate the feasibility and surgical outcome of robotic radical hysterectomy in patients with cervical carcinoma using the da Vinci surgical system.
Methods : We retrospectively reviewed the record of ten patients who underwent robotic radical hysterectomy at our institute from March to July 2011. Patient status was estimated in terms of operative morbidity, length of surgery, docking time,estimated blood loss, yield of pelvic lymph node and hospital stay
Results : Seven of the ten patients were Stage I. Three of them were post NACT. The median age was 55.The mean body weight was 63.2 kgs. There were no conversions to laparotomy. The mean operative time was 256 min. Docking time on an average was 30 min. The mean blood loss was 120 ml. The average number of pelvic lymph nodes resected was 26.2 (13–41).One of them developed perforative peritonitis and subsequently ureteric fistula.
Conclusions:Robotic radical hysterectomy is feasible and associated with minimal morbidity.However long term oncologic outcome is yet to be evaluated.
47) Title—Pancreatic Neuroendocrine Carcinoma—A Case Report& Review of Literature
Authors—Dr. Balaji R, Dr. A.S. Ramakrishnan, Dr. B.J. Sunil
Hospital/ Institute: Cancer Institute (WIA), Adyar, Chennai. drbalaji5@gmail.com
Key Words—Pancreatic Endocrine tumor, neuroendocrine carcinoma, Whipple’s procedure.
Introduction: Pancreatic Endocrine Tumors constitute about 3% of pancreatic tumors with varied presentation, clinical management& prognosis.
Case Report: A 14-year-old boy was evaluated for a large mass in the head of pancreas and underwent Whipple’s procedure with saphenous vein patch repair of the Superior mesenteric-portal vein confluence. The final histopathology report was a well differentiated neuroendocrine carcinoma of the pancreas. The clinical presentation, operative& post operative management is discussed.
Discussion: Pancreatic Endocrine Tumors(PET) are rare malignancies with an incidence of The mainstay of treatment is complete excision. Pathological features, Immunohistochemical studies& genetic analysis play a role in the management of these tumors with recent developments in the management of advanced tumors with targeted therapy, somatostatin analogues& biological agents.
Conclusion: PET’s are a heterogeneous group of tumors that are managed based on the stage& functional status. Surgery is the mainstay of therapy with other modes of therapy being reserved for advanced unresectable disease.
48) Mutation of the PTEN tumor suppressor gene is not a feature in oral squamous cell carcinoma (OSCC)
Nisreen Sherif Alyasiri M. Moshahid Alam Rizvi
Department of Biosciences, Jamia Millia Islamia, New Delhi 110025. nis_reen76@hotmail.com
Key words: OSCC, PTEN, PCR- SSCP.
Introduction: India has one of the highest incidences of Oral cancer in the world. PTEN tumor suppressor gene has been described to be mutated in many different tumors. However the involvement of PTEN genetic alterations in OSCC progression still controversial.
Aims and objectives: To explore whether PTEN mutational alteration is associated with OSCC.
Methods and Materials: Genomic DNA was extracted from 100 fresh tissue biopsies collected from patients with OSCC at LNJP hospital- New Delhi. To identify mutations of PTEN gene, entire exons (1to9) were screened by PCR-based single stranded conformational polymorphism PCR-SSCP. Nine oligoneoclutide primer sets were used to amplify all exons. To validate the PCR-SSCP results, each exon were directly sequenced in two randomly selected samples using the same primers.
Results: No mobility shift was observed in SSCP patterns in exons 1–9 referring that there were no any mutations. DNA sequencing confirmed the accuracy of PCR procedures.
Conclusion: The present study revealed that Mutation of the PTEN gene is unlikely to be a feature in OSCC.
Discussion: The studies on PTEN in OSCC showed frequent genetic alterations but still there is inconsistency. Many other investigators, however, have suggested no any direct relationship between PTEN and OSCC existed. Taken together, these reports suggest that PTEN plays a crucial but limited role in OSCC.
49) Initial Experience Of Radical Cystoprostatectomy With Urinary Diversion Using Da Vinci Surgical System
Dr Shamima Akhter(presenter), Dr Robin Joshi, Dr Fouzia Rashid, Dr Samir Khanna, Dr Sudhir Rawal
Rajiv Gandhi Cancer Institute And Research Centre Delhi. sheikhshanoo@gmail.com
Objective:
Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 16 consecutive cases of robotic assisted radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications.
Materials and methods:
A total of 16 consecutive patients (13 male and 3 female) underwent robotic radical cystectomy and urinary diversion at our institution for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate.
Results:
Mean age of the pts was 65 years. Of the 16 patients 4 underwent ileal conduit diversion, and 12 received ileal neobladder. Mean operating time was 7 h and mean surgical blood loss was 350 ml . Mean hospital stay was 9 days .On histopathology 50% of the cases were pT2b , 25% were pT3, 2% had T4 and 23% had no residual disease . Mean number of lymph nodes removed was 19. In no case was there a positive surgical margin. There were 3 postoperative complications in 16 patients, 1 pt had Clavien grade 3 and 2 pts had Clavien grade I complication
CONCLUSIONS:
Our initial experience confirms that robotic radical cystectomy is feasible with acceptable morbidity and good short-term oncologic results.
Key Words: Da Vinci, Robotic—Assisted, Radical cystectomy. Appropriately.
50) Abstract
Title :PROGNOSTIC SIGNIFICANCE OF ER/PR EXPRESSION IN BREAST CANCER
AUTHORS : Dr Prashant S Patil, Dr D K Sarkar
Hospital: SSKM/IPGME&R, Kolkata. docprashant2010@gmail.com
Key words :NPI,ER/PR status,LABC
Introduction :ER/PR expression is traditionally assessed in breast cancer tissues for consideration of hormone therapy post-operatively.Their expression is considered to be good prognostic markers in breast cancer.However,no study has yet shown any relation between tumor size,lymph node status,histological grade and Nottingham Prognostic Index.We conducted a study to find relation between above factors and ER/PR expression and also the incidence of ER/PR expression in Indian population.
Aims :1)Study the incidence of ER/PR expression in Indian patients
2)To correlate the biomarkers with tumor size,grade,nodal status,NPI
3)To delineate the biological behaviour of breast cancer with respect to ER/PR.
Methods :Study area :Surgical outpatient department of SSKM Hospital,Breast clinic at SSKM Hospital
Study population :All clinically diagnosed patients of breast cancer (n = 185)
Study period :June 2009–June 2011
Study :Combined prospective and retrospective study
Results :1)In majority of breast cancer patients,ER/PR are not expressed
2)ER/PR expression is associated with higher incidence of lymph node metastasis
3)Locally advanced breast cancer patients show negative ER/PR status
4)Tumor size >5 cm and histological grade III have higher negative ER/PR expression.
Conclusions :Indian patients are genetically different than their western counterparts.
ER/PR expression can predict response to hormone therapy but cannot assure improved survival in patients.
Large sample size studies are required involving Indian patients as 30% cases in our country are of LABC
Discussion :Treatment strategy for Indian breast cancer patients is different than for western patients.
51) Abstract
Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer
S Bal, R Kumar, P Srikhande**, RK Mani*
Department of Thoracic Surgery & Thoracic Surgical Oncology, Pulmonology* and Critical Care
Fortis-Escorts Hospitals
Delhi & NCR. drsbal@gmail.com
Key Words: Video-assisted thoracic surgery • prognostic factors, case selection • Stages I and II in NSCLC
Objective: The best prognostic indicators for VATS for cancer lung are not well known. Therefore, we review here a series of patients who underwent VATS lobectomy at our hospital, and we attempt to identify the factors that influence the survival of VATS patients and the backgrounds of such patients.
Methods: A thoracoscopic curative approach was attempted in 68 patients from January 2006 to December 2010. 14 were converted so the procedure was successful in 54 patients.
We retrospectively reviewed the VATS patients with non-small cell lung cancer (NSCLC). All patients were subject to lobectomy including dissection of hilar and mediastinal lymph nodes that were in pathological stage (p-Stage) I or II. (Video 1&2).
Our VATS approach initially was a hybrid technique, employing three ports and a small (7 cm diameter) utility thoracotomy to allow access for the instrument and a view initially but the last 15 patients were done using total thoracoscopic techniques.
Results: The Kaplan–Meier probabilities of survival at 5 years were VATS, 77.3%. According to a univariate analysis of survival curves, the significant prognostic factors (P
Conclusion: Stringent selection of candidates for VATS in NSCLC at pathological stages I and II could be an acceptable and valuable approach.
52) Abstract
TITLE:SERUM CARCINOEMBRYONIC ANTIGEN LEVELS IN PATIENTS OF GASTRIC CANCER—IMPORTANCE AS A PREDICTIVE FACTOR FOR OPERABILITY
AUTHORS: Dr. Saratchandra Pingali, Dr. Veerendra Kumar, Dr. Vijayalaxmi Deshmane, Dr. Syed Altaf
INSTITUTE: Kidwai Memorial Institute of Oncology, Bangalore. dr_pscms@yahoo.co.in
KEY WORDS: Carcinoembryonic antigen, gastric cancer, operability
INTRODUCTION:
Carcinoembryonic antigen[CEA] is a protein polysaccharide complex that is proven to be of clinical usefulness in colorectal cancer. About one third of patients of advanced gastric cancer can have elevated circulating CEA levels.
AIMS & OBJECTIVES:
The aim of the current study is to assess the incidence of elevated CEA levels in patients of gastric cancer deemed operable preoperatively & to correlate their elevation, if any, with actual operability based on intraoperative findings.
METHODS & MATERIALS:
Twenty-nine patients of gastric cancer deemed operable based on preoperative evaluation also underwent serum CEA level estimation as part of their preoperative workup. Patients underwent laparotomy & intraoperative assessment of operability. Tumors found to be operable were resected. The predictive value of CEA for inoperability was assessed.
RESULT:
Out of 29 patients who underwent laparotomy for gastric cancer, 12 patients had elevated serum CEA levels. Out of 12 patients with raised CEA levels, 4 patients had operable disease & 8 had inoperable disease at laparotomy [67% predictive value for inoperability when raised]. Out of 17 patients with normal CEA levels, 15 patients had operable disease at laparotomy [88% predictive value for operability when normal].
CONCLUSION:
Serum CEA level in patients of gastric cancer can be a subtle indicator of inoperability when done preoperatively in some of the patients. These findings need to be validated in larger groups of patients.
DISCUSSION:
Serum CEA levels in patients of colorectal cancer are known to be of prognostic importance & clinical usefulness. Clinical application of this tumor marker for gastric cancer is a likely possibility & needs to be studied further in larger groups of patients.
53) Abstract
CERVICAL ESOPHAGOGASTRIC ANASTAMOSIS : A RETROSPECTIVE STUDY COMPARING HAND SEWN VERSUS SIDE-SIDE STAPPLED ANASTAMOSIS.
ARUN NARASANNAIAH, PROF. M. VIJAY KUMAR, PROF. K.V.V.KUMAR. PROF. S.K.MURTHY.
KIDWAI MEMORIAL INSTITUTE OF ONCOLOGY,DR. M.H.MARIGOWDA ROAD,BENGALURU-29
arunsunchariot@yahoo.com
BACKGROUND: The Anastamotic Leak & Stricture are among the leading causes of Outcome after Esophagectomy for carcinoma esophagus.
OBJECTIVE: To Compare the Outcome of Hand Sewn (HS) and Side-Side Stappled (SSS) methods of Cervical Esophago-Gastric Anastamosis (CEGA).
MATERIAL and METHODS: There were 182 cases of Carcinoma Esophagus, who underwent Esophagectomy from Jan 2005–Jan 2011 at KMIO Bengaluru, considered for the study. The age group ranged from 32 to 77 years, Males-94 and Females-88.There were Middle third-91,Lower third-67, GE Junction Tumors -24 cases. Among them 148 patients underwent THE , 35-TTE , 7- VATS Assisted Esophagectomy and 2- Palliative Substernal Bypass procedure.The Cervico Esophago Gastric Anastamosis done by Hand sewn (HS) Method in 142 and Side to Side Stappled (SSS) Method in 40 Cases. The Post operative Complications, Adjuvant Treatment and the outcome of Anastamosis viz Leak and Stricture compared between HS and SSS Methods using Chi-Square Test. Follow up ranged from 6 m–5 years.
RESULTS : The Anastamotic Leak were 16(11.26%) and 3 (10%) with p =0.95 whereas the Anastamotic Stricture were 22 (15.5%) and 2(5%) with p = 0.04 ,noted among HS and SSS Methods respectively.
CONCLUSION: The Hand Sewn and Side-side Stapled methods of CEGA are followed in Esophageal Cancer Surgery, the latter method has better Outcome with less morbidity.
Keywords: Esophagogastric Anastamosis, Stappled Anastamosiis.
54) Abstract
Surgical salvage for post radiotherapy recurrent carcinoma cervix
Mira Wagh, P. Rema, S. Suchetha, Jem Prabhakar, P. Sebastian
Division of Surgical Oncology, Regional Cancer Centre, Trivandrum. mirawagh@gmail.com
Keywords: recurrent cervical cancers, surgery
Background: For patients with recurrent cervical cancers after primary treatment with chemo radiation, surgical salvage may be the only therapeutic approach.
Objective: To analyze the impact of radical surgical resection on survival of patients with recurrent cervical cancers.
Methods: All patients who underwent radical surgery for cervical cancer recurrence after primary chemoradiation from January 2004 to December 2009 were analyzed for morbidity and survival.
Results: Twenty patients underwent radical surgery for recurrent carcinoma cervix during the study period. Mean age was 49 years. Histology was squamous cell carcinoma in 17 and adenocarcinoma in 3 patients. Mean disease free interval was 22.5 months. Thirteen patients underwent pelvic exenteration (total exenteration -8, anterior exenteration -3, posterior exenteration-2). Seven patients underwent radical hysterectomy with pelvic node dissection. After a median follow up of 25 months the median survival time for the exenteration group was 28 months and 14 months for the radical hysterectomy group. Three year overall survival for the entire cohort was 43%. Vault recurrence was noted in two patients in the hysterectomy group. Operating time, blood transfusions needed, hospital stay and post operative morbidity were more in the exenteration group.
Conclusion: Surgical salvage offers acceptable survival without added morbidity in recurrent cervical cancers. Hence radical surgery should be offered in selected patients with recurrent cervical cancers.
55) Abstract
Title :—Ultra Radical resection of Advanced Buccal and GB Sulcus tumors : feasibility and impact on survival
Authors :—Nirav P. Trivedi, Vikram D. Kekatpute, Mandeep S. Malhotra, Girish Shetkar, B.V. Manjula, A. Mathan Mohan, Deepak C. Kittur, Moni Abraham Kuriakose
drmandy79@gmail.com
Institute :—Department of Head abd Neck Oncology, Mazumdar- Shaw Cancer Center, Narayana Hrudayalaya, Health City, Bangalore, India
Introduction
Advanced Buccal and GB sulcus tumors with pan buccal, skin or ITF and masticatory space involvement are considered to have a poor prognosis.. They are reported to have a post surgery local failure rate of around 30%. These tumors are generally not offered surgery as the primary modality
Aim
The aim of this study was to evaluate the feasibility of surgery in terms of post op morbidity, margin negativity, local recurrence rate and also assess the impact of pterygoid muscle and plate involvement on local relapse rate.
Materials & Methods
A total of 42 patients comprising of large T3, T4a and T4b patients with regional metastases underwent radical resection with microvascular reconstruction from August 2009 to March 2011. The resection was carried out as ‘Compartmental Resection’ comprising of Wide Local Excision with usual >2 cm skin margin Hemimandibulectomy, partial maxillectomy and ITF clearance in patients having tumors that reach or involve RMT and those with radiologically documented ITF or masticator space involvement. ITF clearance was done by removing masticatory muscles from origin to insertion and pterygoid plates were taken as margin. These patients were subjected to adjuvant chemoradiotherapy or radiotherapy according to histopathology report. A retrospective analysis of patient records was done with update on follow up.
Results
The median follow up was 18 months. Margin negativity rate was 93%. 19 patients had pathologically proven pterygoid muscle involvement with 7 patients had pterygoid plate positivity. The post op surgical morbidity was not significantly higher in patients with T4b disease. 4 patients relapsed locally with one patient had pulmonary metastases with LR. The recurrence rate in T4b patients[ pterygoid positive] was not higher than T3 or T4a patients.
Conclusion
Although our median follow up is 18 months, most of the local recurrences in Buccal Carcinoima are reported to occur within 24 months. Our local relapse rate of just 9% highlights the role of radical surgery in these advanced tumors in achieving adequate disease control, since Buccal carcinoma rarely locally first and then distally. In the era of microvascular reconstruction such radical resections have become feasible without much morbidity and radical compartmental resection should be the primary modality of treatment rather than primary chemoradiotherapy.
56) Abstract
Efficacy of Contrast Enhanced MRI in node negative Early Breast Cancer: A non-invasive axillary staging
Syam Vikram, Jem Prabhakar, Arun Peter, Madhu Murali, Iqbal Ahammed, Paul Sebastian
Regional Cancer Centre, Trivandrum. syamdr@gmail.com
Key Words: Early breast Cancer, Axillary dissection, MRI axilla
Introduction: Axillary dissection is the gold standard in assessing lymph node metastasis, is associated with long term complications. Up to 70% of patients with early breast cancer, have negative axilla .Thus, an increasing proportion of women are undergoing unnecessary axillary surgery with its associated long term morbidity.
Aims: To study sensitivity, specificity and predictive values of contrast enhanced MRI in assessing axillary node metastasis and to determine whether it can be used as an alternative for axillary dissection in early breast tumors (tumors up to 3 cm)
Methodology: Histologically proven primary early breast cancers with clinically negative axilla are studied. Patients with significant axillary nodes, previous intervention and contraindication to MRI are excluded. 46 patients with clinically N0 axilla are studied. All patients underwent pre-operative MRI of axilla. It was later compared with the pathology report of axillary dissection. Pathologist was kept blind about MRI report. High resolution images are acquired with GE 1.5 T twin speed high definition Signa Dx Machine, with dedicated breast coils.
Results: 46 patients with mean age of 43 years. Sensitivity, Specificity and Negative predictive values of MRI in our study are comparable with the standard published data. Size, Index quadrant and grade have not found to have any significance with nodal mets.
+ve predictive value (%) -ve predictive value (%)
67 81
Sensitivity (%) Specificity (%)
87 57
Conclusions: Our data shows contrast enhanced MRI has the potential for evaluating the axillary nodes in early breast cancer and may be a reliable method for predicting absence of axillary metastases. Studies involving larger number of patients are essential for standardization of this tool.
57) Abstract
Presence of Human papilloma virus and EGFR expression does not predict response to Neoadjuvant chemotherapy in oral cancer.
Amar Kumar, Mohan Kumar, Manoj Pandey
Department of Surgical Oncology and Pathology
IMS, BHU, Varanasi. amarkr81@gmail.com
Abstract
Introduction
Approximately 25% of head and neck squamous cell cancer, specially oropharangeal are associated with high risk HPV-16, 18, 31, 33, 35. Patient with HPV-16 related tumors tend to be younger, have smaller primary site lesions and experience improved survival compared with patient with HPV-16 negative tumor. Various studies show that patient with HPV positive tumors had upto a 60 to 80% reduction in the risk of cancer death compared to their HPV negative counterparts. A recent study examining biomarkers of response in advanced oropharyngeal cancer identified both high EGFR expression and low HPV titer as being associated with poor outcome.
Aim of study
To correlate the response of Neoadjuvant chemotherapy with presence of HPV and EGFR expression in oral cancer.
Method
HPV status by PCR and the EGFR expression by IHC was studied in 20 patients of locally advanced squamous cell oral cancer were given neoadjuvant chemotherapy docetaxel and carboplatin. Response was evaluated with RECIST criteria. Mean, median and standard deviation were calculated for continuous variables. Responses were correlated with positivity of HPV asserted by PCR and EGFR status.
Result
Majority of the cases had primary tumor of buccal mucosa (25%), lower alveolus (25%) and tongue (25%). HPV 16 was positive in 5 patients (25%) None of the patient was HPV 18 positive. Level of EGFR expression was 1+ in 6 (30%) 2+ in 5 (25%) and 3+ in 9 patients (45%). 14 patients (70%) were given 3 cycles, 2 patients (10%) 4 cycles, 3 patients (15%) 5 cycles, 1 patient (5%) 6 cycles. 5% of patient showed complete response, 45% partial response, 30% stable disease and 20% progressive disease. There was significant relation of response with bleeding at the time of presentation (x2 = 8.235, p = 0.041) showing a stable disease and site of tumor (x2 = 27.037, p = 0.008) with patients with buccal mucosa, lip and alveolus having a better response than retromolar trigone and tongue lesions. No significant relation was seen with growth type, pretreatment T stage, grade, HPV status and EGFR status.
Conclusion
Human papilloma virus and EGFR expression does not predict response to neoadjuvant chemotherapy in oral cancer.
58) Abstract
Title: Thoraco Abdominal flap In locally advance breast cancer-A Malaysian Experience
Author: Dr D. K. Das
digantadas03@gmail.com
UCSI University, Malaysia
Key words- Locally advance breast cancer, Thoraco-abdominal(TA) flap
Introduction: Locally advance breast cancer ( LABC) is a major concern due to its large numbers of cases, treatment complexity specially to reconstruct the chest wall after radical surgery.
Aims & Objectives: to asses the operative advantages of TA flap in various aspect, patient compliance and tolerance to adjuvant radical radio therapy.
Methods & Materials: over a period of one and half years LABC cases attended surgical clinic for treatment in which primary closure of chest wound was not possible due to large defect were included in this prospective study.
Results: all twenty patients recovered well except one patient who had minor flap necrosis. Operative time was satisfactory and compatible with other studies already published in literature. Adjuvant radiotherapy tolerated well by all the patients.
Discussion: TA flap cover is a easy and suitable procedure for chest wall cover after radical breast surgery and in all setting any surgeons with minimum resources can perform this procidure. It is cost effective as well. Our results were compatible with earlier published results in various literature.
Conclusion: looking at various advantage of TA flap it can be concluded that TA flap can consider as a first choice of procedure for Chest wall cover in LABC patients.
59) Abstract
Title: Functional outcome in Extensor mechanism reconstruction with mesh-myoplasty in limb salvage surgery for proximal tibial tumors
Authors: Vinay Gadgi* Kathiresan N+
*Resident in surgical oncology. + Professor of surgical oncology
Dept. Of Surgical Oncology, Cancer Institute (WIA) , Chennai. vinaygadgi@gmail.com
Keywords: extensor mechanism reconstruction, tibial limb salvage surgery, mesh-myoplasty
Introduction: Limb salvage surgery in tumours of the upper end of the tibia encompasses several challenges. Among those challenges, lack of soft tissue cover and difficulty in reconstructing extensor mechanism of the knee joint are important.
Aims and objectives: To know the functional outcome and quality of life in patients undergoing mesh-myoplasty v/s myoplasty in tibial limb salvage surgery.
Materials and methods: Retrospective analysis of 40 consecutive patients who underwent limb salvage surgery for proximal tibial tumours with custom made prosthesis at our institute from 2001 to 2010. Reconstruction of the patellar tendon was done by attaching the patellar tendon to the gastrocnemius muscle till 2007. Since 2007 the reconstruction was done by anchoring the patellar tendon to the tibial prosthesis using polypropylene mesh. Quality of life analysis was done using the Cancer Institute QOL questionnaire. Functional outcome of the extensor mechanism reconstruction was measured by quantifying the extensor mechanism lag using callipers.
Results: Of the 40 patients who were analysed ,QOL was obtained for 32 patients which includes 12 patients in myoplasty arm and 20 patients in mesh-myoplasty arm. There was no difference in the QOL between the two groups. Extensor lag was measured in 7 pts with myoplasty and 14 pts with meshmyoplasty. The mean lag in patients with myoplasty was 67.14o and in mesh-myoplasty was 41.43o. 28.6% of the patients with mesh-myoplasty had a lag of less than 20o, where as none among those who had undergone myoplasty had a lag of less than 20o.
Conclusion: Mesh-myoplasty provides better functional outcomes with less extensor lag, even though the difference in QOL between the two groups is not significant.
Discussion: Mesh-myoplasty done by using polypropylene mesh to reconstruct the extensor mechanism provides an efficient and economical way of reconstruction
60) Abstract
Mode of Presentation: Poster
Title: Second primaries in cancer survivors treated at a tertiary care centre—possibility of an unknown etiology.
Authors : Kannan N, Kulshreshtha Pranjal, Takkar P, Sanchety N, Batra Swati.
pranjal7088@gmail.com
Institute: Army Hospital (Research & Referral), Delhi Cantt, Delhi-10
Key words: synchronous, metachronous, cancer survivors
Introduction: In the past 3 decades, the number of cancer survivors has tripled, reaching approximately 10.7 million in 2004. Subsequent malignancies among this high-risk group account for about 16% (or 1 in 6) of all cancer incidences. Multiple primary cancers can be grouped into three major categories according to predominant etiologic influences (i.e., treatment-related, syndromic, and those due to shared etiologic factors). Aims & Objectives: The present study was conducted to evaluate the incidence of second primaries in long term cancer survivors treated at our hospital. Methods & Materials: The study was conducted by retrospective analysis of records of all patients treated at our Hospital in the past 5 years, with identification of patients developing multiple primaries. Detailed epidemiological data was thereafter collected for these patients with particular reference to risk factors and outcome. Results: 28 patients were identified in the last 5 years with a total of 57 malignancies. Bilateral breast tumors were the most common (5/28 patients), followed by gallbladder with ovarian cancer (2/28), rest all being solitary combinations. Breast cancer was the most common malignancy (present in 12 patients), followed by ovary (5), HNSCC (5) and colon (4). Although genetic testing was not available for any patient, 5 patients fell into possible syndromes. 7 patients had possible shared etiology as the cause of the multiple primaries, while none appeared to have therapy related cancers. Thus, 16 patients were left with no possible etiology. Conclusion—Second primaries in cancer patients are an important and not so uncommon entity , which should be actively ruled out in the face of findings before labelling them as metastatic. The etio-pathogenesis of the majority of these cancers does not fall into known causes and further research is required for the same.
61) Abstract
Title : Is Her 2 / neu a useful prognostic marker in clinical practice . ?
Authors :
Dr. Bhargava Ram(speaker)
Dr. Bitan K. Chattopadhyay, Dr. Diptendra K. Sarkar.Debarshee Jana
bhargava.chikkala@gmail.com
Introduction : Breast is a fast rising and a very common cancer not only in the Indian scenario but also the world . It has always been an area of great interest of research and a very rapidly changing and evolving modes of treatments and research . It is a well known fact that Hormone receptor status is a key prognostic marker in these patients . Though there has been some controversy regarding the usefulness of the Her2/neu status and its role in prognosis , we evaluated a group of patients and their prognosis in relation to their Her2neu status.
We evaluated a total of 123 patients over the past 2 years duration, and their prognosis has been evaluated based on their NPI score and their disease free survival at the end of 1 year .
Aims & Objectives :
To evaluate the efficacy and usefulness of Her 2 Neu therapy in our patients and its significance in the risk stratification of breast cancer patients.
Materials & Methods :
The patients diagnosed to have breast cancer were operated and have been categorized based on their age , sex , T,N,M status , NPI , and over all survival at the end of 1 year in relation to their Her 2 / neu status .
This was a prospective case control study done at our instituition over 2 years.
Results :
45.5% of our Her 2 /neu negative patients are ER positive
45.7% of our Her 2 /neu positive patients are ER negative
Table 1 :
Her 2 / neu—Her 2 / neu + test of proportion
Nodal status I 11 9 >0.05 p = 0.717
2 23 14
3 44 23
Grade 1 7 2
2 29 22 >0.05 Chi square 1.77
3 41 22
Table 2 :
Her 2 / neu—Her 2 / neu +
NPI 1 26 20
NPI 2 51 26
P0.05
Table 3 :
ER + Her 2 / neu -
NPI 1 33 26
NPI 2 27 51
P
TOTAL NO. OF TRIPLE NEGATIVE PATIENTS : 37 ( 30%)
NPI 1 2
NPI 2 35 p
Conclusion ;
Risk stratification is not possible with Her2/neu
Her2/neu can only be used only if molecular target therapy is contemplated
Her 2 / neu target therapy is not affordable in most of our patients
Routine Her2/neu assay beyond research purpose does not give any benefit in clinical practice
30% of our patients are triple negative and they have a poor prognosis
Patients in whom their ER and PR status have been negative their Her 2 neu negativity did not alter their pronosis statistically
Bothe Her 2 neu positive and negative patients have almost the same overall survival
62) Abstract
Title : Auto amputation of penis in penile cancer—an extreme self neglect.
Authors : Dr. Sivaprakash Rathanaswamy, Prof. Sanjeev Misra
Institute : Chatrapati Shahuji Maharaj Medical University (CSMMU), Lucknow. dr_sivaprakash80@rediffmail.com
Introduction:
Autoamputationof penis are often reported after self emasculation as a result of psychiatric diseases,hair strangulation of penis, paraphimosis because of hemangioma, and as a manifestation of ulcerative colitis. It has also been reported as a result of locally advanced penile carcinoma. Cancer of the penis is a rare disease, represents less than 0.5% of cancers in men. The annual age-adjusted incidence of penile cancer is 2.0 to 10.5 per 100 000 in India.Early symptoms of penile cancer were neglected by our patient leading to autoamputation of penis and presented with advanced disease.Even in this era of advanced medical care, such a presentation of penile cancer exists.
Case summary :
Two middle aged men presented with history of ulcer on the tip of penis for 1 year duration and sloughing of whole of the penis for 2 months duration. Examination revealed auto amputation of penis with fungating inguinal lymphnode mass. Both of them were treated with palliative chemotherapy. One patient succumbed to the disease after 6 months and the other one lost to follow up after 18 months.
Discussion :
Patients with penile carcinoma seek medical attention later than patients with other types of cancer. Starting treatment is delayed for longer than 1 year in 15–50% patients as a result of fear, embarrassment, ignorance, and personal neglect. Without treatment, patients with penile carcinoma usually die within 2 years. Spontaneous remission has not been reported. In developing countries like India, where there is a higher incidence of penile cancer, measures should be taken to educate patients regarding symptoms and signs of penile cancer, importance of maintenance of personal hygiene, protection from cancer due to neonatal circumcision and advantage of early treatment of sexually transmitted premalignant conditions of penis.
Conclusion:
Auto amputation of penis is a rare phenomenon. The two case reports discussed show the extreme step of self neglect seen in low socio economic status people in India. Penile cancer, although amenable to both primary and secondary prevention, has mostly been ignored as a public health issue.
Key words : Penile carcinoma, auto amputation, metastasis.
63) Abstract
title: microvascular reconstruction in case of head & neck carcinoma
author: dr K P Singh, Col S Mehrotra, Lt Col M Mathur
karam5338@yahoo.co.in
hospital: command hospital (CC)
key words: SCC face, Radial artery forearm free flap
introduction: case report
20 year male albino farmer, c/o SCC face
presentation: multiple progressive fungating friable growths 1–6 cm over b/l zygomaticotemporal regions of the face R > L, which bleed profusely on touch; & generalised solar keratosis
onset: 4 years
incision Bx HPE: MD SCC
Op plan: WLE + flap reconstruction Estimated defect 15 x 9 cm. no locoregional reconstructive options feasible; planned for radial artery forearm free flap, template marked
per op- WLE done, free fasciocutaneous radial artery forearm flap (lt), flap defect of lt forearm covered by SSG & primary closure, microvascular anastomosis of radial artery to facial artery & proximal (cephalic/basilic) vein to external jugular vein done, flap inset
post op- uneventful, good arterial + venous flow present, flap & donor site healthy
HPE: non keratinising MD SCC, margins free
Discussion: options in reconstruction have to be evaluated from simple to complex
Microvascular surgery and free flap is a relatively new and exciting option. It has much fewer limitations as compared to locoregional options. It permits extensive uncompromised oncological clearance while restoring both function and aesthesis.
Conclusion: reconstructive surgery collaboration at the time of primary oncosurgical procedures should be considered in the best interest of the patient.
64) Abstract
Nasolaabial flap reconstruction in oral cancer
Seema Singh, Rajesh Kumar Singh1, Manoj Pandey1
seemasingh5jan@gmail.com
Department of Surgery and Surgical Oncology1
Institute of Medical Sciences, Banaras Hindu University
Varanasi 221 005, India
Abstract
key words: nasolabial flap ,reconstruction, orocutaneous fistula,facial artery
Background
Nasolabial flap is a simple flap for reconstruction of small intra-oral defects created after excision of malignant tumours.
Methods
Retrospective analaysis of 26 cases of oral cancer treated with primary excision and nasolabial flap reconstruction was carried out. In 22 cases the excision was combined with neck dissection and facial artery ligation.
Results
Good cosmetic and functional results were obtained in almost all cases. Wound dehiscence developed in 3 patients and 1 developed persistent orocutaneous fistula. Disease recurrence occurred in one patient.
Conclusions
Nasolabial flap is a good flap for reconstruction of small oral defects after excision of primary tumors and results in good overall cosmetic and functional outcome.
65) Abstract
Title : To evaluate a new technique of axillary dissection in patients undergoing surgery for carcinoma breast
Author: Dr P Jaiswal, Dr N K Saidha, Dr L S Vohra
drjaiswalpradeep@yahoo.co.in
Institute
Command hospital southern command Pune
Command Hospital Air force Bangalore
Keywords
Axillary dissection; fascial envelope; extrafascial dissection
Introduction
Axillary dissection integral part of breast surgery in node positive patients. In contrast to surgical procedures related to breast which has been extensively researched in literature there is paucity of articles describing techniques of axillary dissection. This study was based on premise that axilla is a fascial envelope and all important neurovascular structures are outside it. Hence by remaining in proper planes this dissection could be accomplished with ease without risk to vital structures.
Aim
To describe a technique of axillary dissection in carcinoma breast
Material and methods
The study was conducted at tertiary level hospital of armed forces.. Patients with operable, node positive breast cancer formed part of the study. Patients underwent axillary dissection as per the technique described.and were followed up till a year.
Results
A total of 44 patients were included in study. Mean lymph node yield was 14.6 (Range 6–28). Axillary weight in our series didn’t correlate with lymph node yield
None of the patients had any major intra or postoperative complications . A total of 15 (34%) Patients developed seroma in post operative period which required aspirations .Six Patients had minor wound complications.
Almost 54% of patients developed numbness over medial portion of arm and axilla. However most of patient reported recovery of symptoms on subsequent follow up. Significant postoperative lymph edema was seen in 13.5% of our patients. Shoulder movement restriction was seen in only 4.5% of our patients
Discussion
In our study the technique was easy to adopt and reproduce. The lymph node yield was adequate.Complication rates were camparable to those described in literature.
Conclusions
In this study details of a new technique of axillary dissection by an ‘extrafascial approach’ has been described. The technique is reliable, safe easily reproducible complication rates associated with this technique compared favourably to those mentioned in literature.
66) Abstract
Sentinel node biopsy combined with detection of micrometastasis in carcinoma of the buccal mucosa
1Seema Singh, 1Manoj Pandey*, 1Umakant Gaud, 2Mridula Shukla,
1Senniappan Karthikeyan, 2Mohan Kumar
seemasingh5jan@gmail.com
Department of 1Surgical Oncology and 2Pathology, Institute of Medical
Sciences, Banaras Hindu University, Varanasi, India
*Corresponding author
Introduction
Carcinoma of the buccal mucosa is a common cancer in India, the incidence is particularly high in North India .This is a locally aggressive malignancy with a low propensity to nodal or distant metastasis. Presence of lymph node metastases in neck is considered as an adverse prognostic factor. Aim of this study was to evaluate role of sentinel lymph node biopsy by using blue dye and immunoshistochemistry for cytokeratin in identifying in occult metastasis in neck N0 neck in patients with carcinoma buccal mucosa.
Patients and methods
Between 2006 and 2008, 28 consecutive clinically and radiographically node negative previously untreated patients were enrolled in prospective study. In the operating room peritumoral injection of 2.5% isosulfan blue dye was given followed by dissection of blue node. All sentinel nodes found to be negative on histology were stained with cytokeratin antibody by immunoperoxidase method.
Results
Sentinel node was identified in 27 patients. A total of 37 nodes were harvested at an average of 1.3 nodes per neck. Sentinel nodes were distributed in five cases in level Ia, 14 cases in Level Ib, 8 cases in level IIa. Of the 37 harvested nodes 14 were positive and 23 were negative for metastases. One of the negative node was (3.7%) cytokeratin positive. Sensitivity of sentinel node biopsy was 100%.negetive predictive value is 100%, specificity was93.35 positive predictive value is 92.8%.
Conclusions
Sentinel lymph node biopsy with isosulfan blue was able to detect blue node with high sensitivity, with few false negative results .The results show that it can be reliably used to predict status of remaining nodal basin
67) Abstract
TITLE : GIST-EXPERIENCES IN TARTIARY CARE LEVEL HOSPITAL (PAPER)
AUTHOR: DR SYED HASSANUJJAMAN
drhasancmc@gmail.com
INSTITUTION: I.P.G.M.E&R. S.S.K.M. HOSPITAL,KOLKATA
INTRODUCTION: GISTs are the most common sarcoma of GI tract. They are increasingly diagnosed today because of better diagnostic orientation of the clinician, radiologist and pathologist.
AIMS & OBJECTIVES: The study takes into account the age, distribution, mode of presentation, diagnostic modalities, treatment including surgery and the role of Imatinib. It also analyses the recurrence pattern and risk categorization of the cases. Finally it brings to forefront the vital role of immunohistochemistry in the diagnosis and management of these lesions.
METHOD & MATERIAL: The study is a rectrospective analysis of the patients diagnosed histopathologically. Detailed history was taken as regard to the age, sex, mode of presentation, site of lesion, management modalities and pathology.
CONCLUSION: We firmly believe, local resection with 1–2 cm margin, with the aim of organ preservation should be the principle of surgical treatment. Local recurrences can be notorious and at times elusive. IHC should be done routinely while assessing specimens of GIST, not only because it is the hallmark of diagnosis but also an important predictive factor. Though the study period was short, our study recommends the use of imatinib in the adjuvant setting in high-risk, recurrent and metastatic settings.
DISCUSSION: Most GISTs (85–90%) are c-KIT positive. A few (about 5%) may be CD117(c-KIT) negative. Therefore the diagnosis of GIST for a tumour that is otherwise morphologically typical is not precluded by an absence of c-KIT staining.
68) Abstract
ROLE OF PRE-OPERATIVE SERUM CA 15-3 LEVEL IN RISK STRATIFICATION OF BREAST CANCER IN INDIAN PATIENTS.
(ABSTRACT FOR PAPER PRESENTATION)
AUTHOR : DR. VIKAS SINGH, DR. D.K.SARKAR, DR B.K. CHATTOPADHYAY
piyush0031@yahoo.com
INSTITUTE: IPGMER & SSKM HOSPITAL, KOLKATA
INTRODUCTION
In this study of 55 patients with breast cancer without metastasis at time of primary diagnosis,we have prospectively assessed the role of pre-operative CA 15-3 in identifying patients with low risk & high risk with respect to their overall prognosis,possibility of developing distant metastasis,need for adjuvant chemotherapy , disease free survival ,death from disease. We analysed relation of pre-op serum CA 15-3 to established prognostic markers like tumor size,lymph node status,histological grade,development of distant metastasis,death from disease.
Traditional tumor markers in breast cancer like tumor size,lymph node status,histological grade need tumor sampling,are costly,depend on competence and expertise of cyto/histopathologist.On the other hand,serum is easily accessible,measuring marker is simple,objective,reproducible,cost-effective.Soluble circulating marker ,if found to be accurate prognostic marker,would be ideal candidate for predicting outcome and monitoring treatment course.
AIMS AND OBJECTIVE
To establish correlation between pre-operative CA 15-3 level and patient outcome. (indirectly via NPI)
METHODS
All female primary breast cancer patients treated at Breast Clinic,Dept of Gen Surgery,IPGME&R,SSKM Hospital,Kolkata from Jan 2009 to Dec 2010 had their pre-op serum CA 15-3 measured and it was repeated on 7th,30th post-op day and every 6 monthly for 2 years.
Patients were excluded if any other malignancy was known from their previous history or if staging investigations at the time of diagnosis revealed evidence of distant metastasis.
Patients were treated with either modified radical mastectomy (MRM) or quadrantectomy and axillary lymph node dissection with local radiotherapy (RT).
RESULTS
Test of proportion showed significant association between raised pre-op serum CA 15-3 and high NPI.
Test of proportion showed that pre-op serum CA 15-3 had no significant association with tumor size,nodal status or histological grade (p > 0.05).
CONCLUSION :
This study showed that elevated pre-op serum CA 15-3 was significantly associated with high NPI and thus can predict poor patient outcome.Patients with raised serum CA 15-3 after R0 resection were at significant risk of recurrence. CA 15-3 can risk stratify breast cancer patients in high risk and low risk group.
69) Abstract
Title :- Reconstruction of large composite oral cavity defects: ALT the ideal flap
Authors :- Vikram D.Kekatpure, Nirav P. Trivedi, Mandeep S. Malhotra, Girish Shetkar, B.V. Manjula, A.Mathan Mohan, Moni Abraham Kuriakose
Institute :- Department of Head and Neck Oncology, Mazumdar-Shaw cancer Center, Narayana Hrudayalaya Health City, Bangalore, India. drmandy79@gmail.com
Key Words :- Anterolateral Thigh Flap, Carcinoma Oral Cavity, Composite oral cavity defects
Introduction
Composite defects of oral cavity, consists of both inner mucosal defect as well as the outer skin defect. In patients post ITF clearance the defect is fairly large. Reconstruction of these defects is a great challenge. In the pre microvascular era double flap such as PMMC + DP were used with high morbidity
Aim
The aim of this study was to evaluate the reliability of anterolateral thigh flap[ALT] for reconstruction of these complex defects following ablative surgery.
Materials & Methods
32 patients who required ALT flap reconstruction from January 2010 to January 2011 were observed prospectively from intraoperative to post radiotherapy period. They were analysed in terms of immediate and late morbidity, functional and cosmetic outcomes.
Results
The mean flap dimension was 261 cm2 (range 80–540 cm2). In 21 patients the flap was bi—paddled and used for inner and outer lining for cheek. One flap was lost due to vascular insufficiency and two flaps were lost due to delayed neck wound sepsis after 7th POD. Only 10% had initial minor salivary fistulas and no patient defaulted radiotherapy due to flap morbidity.
Conclusion
The study establishes the safety and reliability large or bipaddled anterolateral thigh flap for reconstructing composite oral cavity defects providing both inner and outer epithelial lining with adequate soft tissue to achieve optimum functional and cosmetic.
Discussion
Large composite defects created after radical resections for advanced Buccal and GB Sulcus tumors are difficult to reconstruct and this is one of the limiting factor for not submitting these advanced tumors to surgery. This study depicts the emrgence of ALT as a very reliable and handy flap to patch these defects with minimal morbidity and optimal outcome, also increasing the resectabilty.
70) Abstract
Breast Conservation Surgery in young women—Should we still hesitate?
Jency Joy Breast Services, Regional Cancer Centre,Trivandrum.
jency_mathews@yahoomail.com
Key words: Breast conservation surgery, oncological outcome
Introduction: Many randomized controlled trials have confirmed overall equivalent survival after breast conservation surgery (BCS) or MRM. Some international clinical guidelines have proposed that age of 35 years or younger should be a relative contraindication for BCS. But a significant proportion of women with breast cancer are less than 40 years of age and desire breast conservation.
Objective: To study the oncological outcome of patients less than 40 years of age with invasive carcinoma breast who underwent breast conservation surgery.
Methods: Patients 40 years of age or less who underwent breast conservation surgery during the period January 2006 to December 2008 at our Institute were analyzed for oncological outcomes.
Results: One hundred and twenty one patients were included for the analysis. The median follow-up was 3.5 years. Five patients (4.1%) had local recurrence alone and 6 (4.9%) had distant metastases alone and 3 (2.4%) had both local and distant failure. The 5 year actuarial local control, progression free survival and disease –specific survival rates were 95.5%, 85.8% and 95.2% respectively. The risk of local recurrence was higher in patients with positive margins. Nodal status was the only predictive factor for overall survival.
Conclusions: The outcomes favor feasibility of breast conservation surgery in selected women with age less than 40 years.
71) Abstract
Title :- Pathological evaluation of sentinel lymph nodes in oral squamous cell carcinoma
Authors :- Nirav P. Trivedi, Vikram D. Kekatpure, Amrutha Suresh, Mandeep S. Malhotra, Subramanium Iyer, Moni Abraham Kuriakose
Institute :-Department of Head and Neck Oncology, Mazumdar- Shaw Cancer Center, Narayana Hrudayalaya Health City, Bangalore, Amrita Institute of Medical Sciences, Cochin , India. drmandy79@gmail.com
Abstract:
Introduction:
Technique to identify sentinel lymph node (SLN) with lymphoscintigraphy using radio labeled substance and gamma camera is now well established in several cancers including that of the oral cavity. The onus is firmly on detecting occult metastasis in dissected lymph nodes.
Materials and method:
In this prospective study, we have systemically compared different methods of pathological evaluation of sentinel lymph nodes. This included frozen section, imprint cytology, routine hematoxylin and eosin (H&E) staining, serial step sectioning (SSS) with H&E and immunohistochemistry (IHC).
Results:
The identified metastases were classified into macro metastasis (>2.0 mm), micro metastasis (0.2 mm to 2.0 mm), isolated tumor cells of less than 0.2 mm size and single tumor cells. Total 192 SLN in 80 patients were harvested. Occult metastasis was detected in 20 patients. Frozen section and imprint cytology identified occult metastasis in 10/20 patients. Routine H&E evaluation detected metastasis in 13 patients, while SSS with H&E and IHC upstaged the disease in seven further patients (9%). Macro metastasis and micro metastases were detected in 8 and 7 patients respectively, while isolated tumour cells (ITC) were detected in 5 patients. Frozen section detected macro metastasis in 7/8 cases but failed to detect smaller deposits in majority of cases (missed micro metastasis in 4/7 and ITC in 5/5). SSS upstaged the disease by 10% and sensitivity and negative predictive value of SSS with H&E was 90% and 97% respectively. Three out of 10 patients (30%) with micro metastasis and ITC developed regional recurrence.
Conclusion: SSS with IHC was required to identify smaller deposits (ITC). Early follow up suggest small metastatic deposits are clinically relevant.
72) Abstract
USE OF METHYLENE BLUE DYE IN PERFORMING SENTINEL LYMPHNODE BIOPSY IN CARCINOMA BREAST PATIENTS.
AUTHOR’S: Dr. Shishir Shah, Dr. Shakuntala Shah.
shishir_shah80@yahoo.co.in
INSTITUTE: Gujarat Cancer and Research Institute (GCRI), Ahmedabad.
KEYWORDS: Methylene blue dye, sentinel lymphnode biopsy, carcinoma breast.
INTRODUCTION:
Sentinel lymph node biopsy is a standard method to stage axilla in early breast cancer patients. A single institution study using methylene blue dye to perform sentinel lymph node biopsy was undertaken. Methylene blue dye proved to be a cost effective alternative to isosulfan blue or radioactive colloid with high accuracy and reasonable sensitivity.
AIMS AND OBJECTIVES:
To study identification rate, sensitivity, specificity, positive predictive value, negative predictive value, accuracy and false negative rate of methylene blue dye use in SLN biopsy.
MATERIAL AND METHODS:
We studied 32 consecutive patients with operable breast cancer in a single institution in a span from August 2005 to May 2008. All the patients with clinical T1-T3 lesions and negative axilla were included in the study.
Exclusion criteria:
Neoadjuvant chemotherapy, Multicentric tumor, Recurrent lesion, Prior axillary surgery.
All the patients had undergone complete axillary lymph node dissection (Level 1 and 2) after sentinel lymph node biopsy as this was a validation study.
Procedure:
2 ml methylene blue dye was taken in dilution with 2 ml saline (total 4 ml), 1 ml was injected peritumorally in all the 4 quadrants (3,6,9,12 o’clock positions). After gentle massage for 2-3 min SLN biopsy procedure was started after 10 min. All blue lymph nodes were removed and sent separately followed by complete ALND in all cases.
RESULTS:
SLN biopsy identification rate: 93.7%, Sensitivity: 92.8%, Specificity: 100%, Positive predictive value: 100%, Negative predictive value: 94.11%, Overall accuracy: 96.64%.
CONCLUSION:
Methylene blue dye is a cost effective alternative to isosulfan blue or radioactive colloid in SLN biopsy especially in developing countries like India with high accuracy, reasonable sensitivity, false negative rate and a high margin of safety.
73) Abstract
EPIDEMIOLOGY AND OUTCOME OF PEDIATRIC RHABDOMYOSARCOMA
Puri Anoop*, Goel Ashish*, Dewan A.K*., Kapoor Gauri**
Surgical Oncology*, Pediatric Oncology**
Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
anooppuri4u@yahoo.com
Introduction Rhabdomyosarcoma (RMS) is the most common pediatric soft-tissue sarcoma. Current multimodality treatment with surgery, chemotherapy & radiotherapy has improved the outcome. Since there is paucity of data from India, we present our experience at RGCI, Delhi.
Aim: To analyze the epidemiological data, treatment & outcome of children less than 18 years with RMS.
Materials and methods: Retrospective analysis of histologically proven RMS in children aged 0–18 years from the cancer registry of our institute from July 1996 to July 2010.
Results: Thirty nine patients were registered. The median age was 6 years (range 2 months–18 year). Male to female ratio was 1.6. Embryonal histology was most frequent (79.4%) & most common sites were head and neck (48.7%) followed by extremities (25.6%) and genitourinary tract (20.5%). Seven patients (17.9%) were metastatic at presentation and most were IRS group III (74.3%). All patients received chemotherapy and the modality of local treatment included surgery alone (n = 9), radiotherapy alone (n = 16) or both surgery and radiotherapy (n = 9); 5 patients did not receive local treatment due to progression (n = 1) or abandonment (n = 4). Event free survival (EFS) was 46.1% at median follow up of 19 months (range 5–74 months) and was higher for head neck (68.4%) compared to extremities (10%) & 48.3% in embryonal compared to alveolar histology (16.6%). EFS was better with both surgery & radiation combined (66.6%) compared to surgery (44.4%) or radiation (50%) alone.
Conclusion: RMS is a common soft tissue tumor in pediatric age group which requires multimodality approach. Outcome is determined by histology, site and clinical stage.
74) Abstract
TITLE : SEROMA FORMATION AFTER MASTECTOMY
Authors : Dr. Bhargava Ram (speaker)
Dr. Bitan Chattopadhyay
Dr. Diptendra K. Sarkar
IPGMER & SSKM HOAPITAL, KOLKATA. bhargav.chikkala@gmail.com
Key Words : Seroma , mastectomy , diathermy
INTRODUCTION:
The importance of the seroma lies in the fact that it is the commenest complication post mastectomy and delays recovery from the surgery and more ofall delays the further treatment such as chemotherapy and radiotherapy to the patients .
The seroma formation post operatively has a poor cosmetic effect as it causes a poor healing of the skin flap , increases the number of visists of the patients to the hospital and also increases the morbidity of the procedure. So effective measures to reduce the post operative seroma formation is a very important part of any mastectomy surgery .
AIMS & OBJECVTIVES :
The patients who were diagnosed to have breast cancers and have been been planned for a mastectomy , have been evaluated to assess the incidence of seroma formation in post mastectomy patients and their causes and also the methods of prevention.
MATERIALS & METHODS :
The patients were divided into two groups , Group A , the patients who underwent the MRM using a sharp dissection(126) and Group B, the patients who underwent MRM using an electro cautery (157).
These patients were randomly applied compression bandage and some were randomly not applied.
In group A , 69 patients had a compression bandage applied and 3 of them only developed a seroma , while the other 55 patients who had no compression bandage post operatively , had only 2 patients who had a seroma formation . In group B , 84 patients patients had a compression bandage, of which 23 had developed a seroma , and 22 of the remaining 73 patients , who had no compression bandage applied.
RESULTS :
The incidence of seroma in our study was 17.66%. The incidence of seroma formation using electrocautery was 28.66% while that with a sharp dissection is 3.96% , he p value < 0.05 , which is significant.
This proves that the electrocautery use is associated with significant incidence of seroma formation.
While evaluating the effect of compression bandage in both the groups of patients , In group A and B , the seroma formation is significantly not related to the use of compression bandage, implying that compression bandage has no role in the prevention of the seroma formation.
n = 283 Sharp dissection (126) Eletrocautery (157)
With compression 69 84
Without compression 55 73
CONCLUSION :
The use of diathermy is associated with a higher incidence of seroma formation, hence its injudiciuos use shoule be restricted.
The post operative compression bandage does not play any role in preventing a seroma formation.
The sharp dissection should be performed in the mastectomy as musch as possible, as it reduces the seroma formation.
The cutting mode of the diathermy may be used if reuqired than the coagulation mode.
DISCUSSION
Several studies have been performed to investigate factors related to post-surgical seroma. These studies have observed that the early removal of drains might led to increased incidence of seroma [12], whereas others have shown that drains removal time had no influence on seroma formation [3].
Porter et al reported that the use of electrocautery to create skin flaps in mastectomy reduces blood lose but increased the rate of seroma formation [11]. In addition, an association of postoperative seroma formation with neoadjuvant chemotherapy was also noted [4]. Compression dressing to prevent seroma rate is a common method used by many surgeons.
75) Abstract
TITLE TOTAL LARYNGECTOMY IN THE ELDERLY
AUTHORS Ashish Goel*, Tapaswini Pradhan*, Abhishek Sharma*, Dilip Nayak*, Sandeep Mehta**, A K Dewan*.
Surgical Oncology* & Reconstructive Surgery** RGCI DELHI. dr_ashishgoel@yahoo.com
Introduction
For a long time elderly patients were not considered good candidates for aggressive therapy and probably were inadequately treated in many instances. Data comparing elderly patients from their younger counterparts are rare, & prospective studies have not been performed due to limited number of cases or exclusion of elderly patients from clinical trials.
Aims & Objectives
To assess the feasibility & outcome of patients older than 70 years undergoing total laryngectomy and neopharynx reconstruction (TL).
Methods
Eighteen elderly patients above 70 years (median age 73) underwent TL at RGCI. Indications were transglottic ca (10), hypopharyngeal ca (2), post RT failure in glottic ca (2) & anaplastic ca (2) cases. Eight patients had ASA Grade III/IV with comorbidities; hypertension (6), diabetes (6), CRF (4), Hypothyroidism (4) & CAD (2). The median body weight was 62 kg.
Results
Patients with upfront surgery underwent TL with SCM buttressing. Four patients underwent salvage surgery for RT failure with PMMC flap buttressing. Median hospital stay was 12 days with no perioperative death. All T3/T4 lesions were offered PORT. Major surgical complications included pharyngocutaneous fistula (3), skin flap failure (3) & carotid blowout in one. Two patients developed stomal recurrence, one developed benign stricture, two were lost to follow up while 11were disease free at a median followup of 12 months.
Conclusion
Total laryngectomy remains a valuable and reliable treatment for advanced laryngopharyngeal cancers in elderly patients due to recent advances in anesthesiology techniques, perioperative monitoring and better postoperative support.
76) Abstract
Prospective study comparing Staged Vs Simultaneous surgeries for primary and nodes in Carcinoma penis.
Dr. A.C. Senthil Kumar, Dr. N. Kathiresan M. Ch. Additional Professor
Department of Surgical Oncology, Cancer Institute (W.I.A) Adyar, Chennai.
drsenthilkumarac@gmail.com
Introduction
Nodal metastasis is the most important prognostic factor in patients with squamous cell carcinoma of penis. Inguinal lymphadenectomy procedures are associated with complication rates as high as 36–80%. Most surgeons practice staged nodal dissection following primary surgery due to higher risk of complications.
Aim
The aim of the study was to compare the morbidity and duration of hospital stay in patients undergoing staged versus simultaneous surgeries for primary and nodes with carcinoma penis
Methods and materials
A total of 56 consecutive patients with carcinoma penis who presented to Cancer Institute, Adyar, Chennai, between january 2006 to December 2009 were evaluated and underwent surgery for primary and nodes. The median follow up was 32 months (range from 12 to 48 months). The patients were analysed with regards to the parameters of wound morbidity, drain removal and long term complications. The statistical methods used for the analysis were Chi-square test, Group statistics, Independent sample’s test, Levene’s test for equality of variances and t-test for equivalence of means.
Results
The study revealed statistically no significant difference in the simultaneous vs staged arms in terms of (i) long term complications (ii ) wound morbidity iii ) Duration of drains and (iv) Hospital stay.
Conclusion
Surgery for primary and lymphadenectomy can be performed simultaneously without increased risk of complications and hospital stay in patients with carcinoma penis.
77) Abstract
ABSTRACT FOR ORAL PRESENTATION
TITLE : The oncologic outcome of High Intensity Focused Ultrasound in the management of organ confined carcinoma of the prostate.
AUTHORS : VEDA PADMA PRIYA .S (presentor), ROBIN JOSHI, SAMIR KHANNA, SURENDER DABAS, SUDHIR RAWAL
Institute : Rajiv Gandhi Cancer Institute, Delhi. privedsri@gmail.com
Background : High intensity focused ultrasound is an ablative strategy in the management of carcinoma prostate. We evaluated the oncologic outcome of HIFU in the management of organ confined carcinoma of prostate.
Methods : Thirty patients of organ confined carcinoma prostate underwent HIFU ablation by Sonablate device. Four of them underwent ReHIFU. They were prospectively evaluated with serial measurements of PSA. Biochemical recurrence was defined according to the phoenix criteria. SPSS 16 was used for statistical analysis by kaplan meier method.
Results : Median age of presentation : 67.59.Mean PSA : 16.27.Mean prostate volume : 21.5 cc.Mean HIFU time was 3 h 40 min.Median follow up : 13 months(0–24). The biochemical relapse free survival as defined by phoenix criteria was 70%.HIFU related Mortality was 0%.Three patients underwent endoscopic necrosectomy on follow up. One of them who underwent ReHIFU developed rectoprostatic fistula.
Conclusions : HIFU therapy promises to be a safe, effective and minimally invasive therapy for patients with localized prostate cancer
78) Abstract
TUMOR ANGIOGENESIS AND PROGNOSIS : CO-RELATION IN CARCINOMA BREAST
Kamlesh Verma1, Prof. Sandeep Kumar 2, Dr A.N. Srivastava3 , Dr M. Goel 4
1. SR, General Surgery, Susrut Trauma Centre, New Delhi
2. Professor, General Surgery, CSM Medical University, Lucknow
3. Professor & Head, Pathology, Era Medical College, Lucknow
4. Professor, Pathology, CSMM Medical University, Lucknow. kamleshverma2001@gmail.com
INTRODUCTION : Angiogenesis is of key importance in the process of tumor progression in a number of tumor types including breast cancer . In my study I have used anti CD34 antibody to assess intratumoral microvessel density (MVD) to estimate angiogenesis and compared it in various prognostic groups.
OBJECTIVES OF STUDY :
To study MVD in malignant breast lumps by immunohistochemistry with CD34 antibody . To compare MVD in different tumor stage, grade and age group. MATERIAL AND METHODS : Part of malignant breast lump removed for tissue biopsy or by mastectomy was used for detection of MVD using antibody against CD34. Counting the number and estimating the density of blood vessels has been used as a measure of angiogenesis. Tumor grading was done as per Nottingham histologic grade and staging was done according to AJCC sixth edition.
RESULTS :
Distribution of Mean MVD in stage l ,ll,lll,lV was 21.0,22.33,27.33,29.33 respectively. Distribution of MVD in Nottingham histologic grade l,ll,lll,lV was 20.80, 24.00, 26.85 respectively . Distribution of M.V.D. in pre and postmenopausal group was 26.5 and 22.0 respectively.
CONCLUSION :
It may be concluded from this study that higher M.V.D. obtained by immunohistochemistry using anti CD34 antibody , are associated with higher tumor stage and grade and indirectly predict poor prognosis. However larger studies with bigger sample size are required to decide cutoff values between different tumor stages and grades.
79) Abstract
Free Paper
TITLE : Prospective study of carcinoma breast with special reference to Clinical, Radiological & Pathological correlation of tumor size & nodal status in operable cases.
Author : Sharma Raj Govind, Galodha Saurabh, Patel Pinakin
Hospital : S.M.S. Medical College & Hospital, Jaipur. rajgovindsharma@gmail.com
Key words : Breast cancer, tumor size, axillary lymph node, mammography, USG
Introduction: Tumor size and Lymph node positivity are important prognostic factors in Carcinoma Breast. There is variation in assessment of size of tumor and Axillary Nodal Status, Clinically, Radiologicaly & on Histopathology.
Aims & objectives : Our aim was to study the difference in Clinical T size, Radiological (USG & Mammography) T size & Pathological T size of tumor and also the axillary nodal status and to find any correlation between T size & Node positivity.
Method &Material : The study includes 115 cases of breast cancer admitted in single surgical unit in Department of general surgery between Sep.2009 to Dec.2010 who underwent surgery (MRM in 107 cases & BCS in 8 cases) . Clinical, Radiological & Pathological comparison was made with regard to tumor size & nodal status to ascertain their accuracy. The association of positive axillary lymph nodes with tumor size was also studied and analyzed.
Results: Average T size in our study was 4.6 × 3.2 × 3 cm. When Histopathology was taken as the base line for tumor size, USG underestimated tumor size by approximately 6 mm where as Clinical examination overestimated T size by 9 mm. Average number of axillary lymph nodes removed was 15.3 in our study of which 53% had >4 positive nodes. Lymph node positivity on clinical assessment had sensitivity 68.2% and specificity 62.9%. In USG it had 77.7% sensitivity and 77.4% specificity. The positive predictive value was increased from 68.3% on clinical examination to 80.4% on USG. Tumor size >1 cm had positive lymph node in 53.7% cases.
Conclusions: It was concluded that small tumor size does not obviate the need for axillary nodal dissection completely & one should subject these patients to additional diagnostic work-up. USG is a modality which can help us predict the nodal status preoperatively fairly accurately. USG is a better modality to ascertain the preoperative tumor size & should be a part of all management protocols for carcinoma breast.
80) Abstract
SINONASAL TERATOCARCINOSARCOMA—A RARE CLINICAL ENTITY
Mira Wagh, Elizabeth Mathew Iype, P Sebastian
Division of Surgical Oncology, Regional Cancer Centre, Trivandrum. mirawagh@gmail.com
Keywords:
Abstract :
Sino nasal teratocarcinosarcoma (SNTCS) is a very rare and aggressive malignant neoplasm characterized histologically by the combination of one or more epithelial elements and mesenchymal components. It has most often been described as originating in the nose and paranasal sinuses. The diversity of histological patterns has led it to be classified under many designations. The term malignant teratocarcinosarcoma was coined by Heffner and Hyams in an attempt to unify the various diagnoses.
We report a 62-year-old man with sinonasal teratocarcinosarcoma involving left nasal cavity and ethmoid sinus. He presented with complaints of epistaxis for 6 months. Computed tomography revealed an enhancing mass in the left nasal cavity, invading left lateral nasal wall and into the left anterior ethmoidal sinus, but with no invasion to the orbit and no intracranial extension. He underwent medial maxillectomy with lateral rhinotomy approach . Histopathology and immunohistochemistry revealed Sino nasal teratocarcinosarcoma. Patient received post-operative radiotherapy. Patient has been followed up regularly for the last 2 years and has been disease free.
81) Abstract
PERSISTENT MULLERIAN DUCT SYNDROME WITH TESTICULAR TUMOR
AUTHORS Shweta Giri, Ashish Goel, Anoop Puri, Samir Khanna, R Sekhon, Sudhir Rawal
Department of Gynae Oncology & Surgical Oncology
Rajiv Gandhi Cancer Institute, Delhi
anooppuri4u@yahoo.com
Introduction
Persistent Mullerian duct syndrome (PMDS) refers to a form of internal male pseudohermaphroditism characterized by presence of mullerian duct derivatives (uterus, fallopian tube, upper part of vagina) in an otherwise normal male. PMDS is an uncommon disorder in men. It presents with male phenotype & genitalia; but with bilateral fallopian tubes & uterus. PMDS patients have unilateral or bilateral cryptorchidism & are assigned to male sex at birth without hesitation. They are genetically 46 XY, with a normal male phenotype, no chromosomal abnormalities with normal testosterone production & responsiveness. It is thought to result from either failure of synthesis or release of Mullerian inhibiting factor (MIF), the failure of end organ to respond to MIF, or a defect in the timing of release of MIF.
Case Summary
We report a case of cryphorchid male who was clinically diagnosed as seminoma in undescended abdominal testis.
A 45 year old male presented with history of swelling in lower abdomen. On examination there was a palpable abdominal lump of 5 × 5 cm in right lumbar region and another 7 × 7 cm mass in left iliac fossa. Scrotum was not developed. Exploratory laparotomy revealed a rudimentary uterus with fallopian tubes and bilateral masses with tumors.
A diagnosis of PMDS was made an intra-operative findings and subsequent histological evaluation.
POSTER PRESENTATION
PRESENTER—DR ANOOP PURI
82) Abstract
TITLE RADICAL CYSTECTOMY IN THE OCTOGENARIAN
AUTHORS Sudhir Rawal, Samir Khanna, Ashish Goel, Anoop Puri, Rakesh Kaul,
SURGICAL ONCOLOGY, RAJIV GANDHI CANCER INSTITUTE, DELHI
anooppuri4u@yahoo.com
INTRODUCTION
Cancer is a major cause of death & morbidity in elderly. In the octogenarian bladder cancer is the fifth leading cause of cancer related death. Although Radical Cystectomy is the treatment of choice comorbidity & unique physiological changes present a surgical challenge in this group.
AIMS AND OBJECTIVES
To evaluate morbidity & outcome of radical cystectomy & urinary diversion in octogenarians with invasive bladder cancer.
MATERIAL AND METHODS
Retrospective analyses of patients older than 80 years who underwent cystectomy during the last 10 years were analyzed. All patients were evaluated for intraoperative & postoperative complications. The median age was 82 years with 10 males and one female. Co morbidities included hypertension (8), diabetes (3) CAD (1) & chronic lung disease (2). Seven patients presented with hematuria, 2 each with LUTS & renal failure.
RESULTS
All patients had ileal conduit for urinary diversion with simultaneous urethrectomy in 2 patients. Median surgical time was 5 h. Median hospital stay was 10 days. One patient had perioperative death due to septicemia. Follow up ranged from 4 months to 5 years. Three patients expired 3 years later due to recurrence & 2 others due to unrelated causes.
CONCLUSION
Our results support the use of cystectomy in octogenarians with invasive bladder cancer with acceptable morbidity & mortality, and offers best chance for sustained disease free quality survival.
83) Proceedings of the Symposium Approach to Neuro endocrine tumors of G.I. Tract in clinical practice (NATCON IASO 2011)
Dr. K. S. GOPINATH
DIRECTOR, HCG
BANGALORE INSTITUTE OF ONCOLOGY & PROF. OF SURGERY & ONCOLOGY SRI DEVARAJ URS MEDICAL UNIV.
TAMAKA, Kolar. Mail. ambujahc@gmail.com
Introduction
Neuroendocrine tumors (NETs) arise in diverse anatomic locations and are classically associated with symptoms resulting from the secretion of hormones or vaso active peptides into the systemic circulation.
Case capsule
Mr. U.K.—age 23 Years of diagnosis -1996 Bleeding/ per rectum Clinical diagnosis rectal polyp Polypectomy done report Carcinoid As there was no evidence of disease in the available imaging modalities at that time patient was asked to come for follow up –surveillance 2003- (Port Land) U.S.A. Recurrence in the meso rectum excised 2004. (USA) recurrent nodal disease, Lt hydronephrosis—Uretric Stenting done liver nodules Two numbers Radiation to local site. Interferon therapy 13-03-05 –Static disease Lap—Cholecystectomy—RF Ablation of Segment IV A & Segment V 2006—Interferron therapy—Discontinued, Progressive diseases. 2007 – PET – CT, 2009—Dotonac Scan done. 31-07-2009—Patient died.
Lessons learnt
Early detection—surveillance, biologically – Indolent tumor - Aggressiveness Metastatic potential Technology – technique - Multidisciplinary.
NET
NETs refer to tumors that originate in neuroendocrine cells throughout the body Including in the thymus, lung, pancreas, gastrointestinal G.I. Tract and less common sites.
Carcinoid tumors and pancreatic NETs should be examined separately Carcinoid and Pancreatic NETs biologically behave differently and response differently to the therapeutic substances.
Incidence
85% occur in GIT, 10% in bronchi, Rest in other organs.
| Site of origin | Organs | Hormones/amines | Carcinoid syndrome |
|---|---|---|---|
| Fore gut | Bronchi, Pancreas, Stomach,Duodenum | Multihormonal, 5HT | frequent |
| Mid gut | Jejunum through right colon, ovary | 5HT, Subs P | frequent |
| Hindgut | Left colon, rectum | Multihormonal | rare |
DIAGNOSIS
Serum Chromogranin A (CgA) is an important tumor marker & helps in Diagnosis and follow up 60–80% of the Functioning tumors—specific hormones Non-functioning tumors—clinical challenge. The further sub classification with the tissues possible with advance molecular markers.
Conclude:
To conclude surgery is the primary modality of treatment for localize NET which varies from conservative local Exision to radical Surgeries. There is no data to support role of Post Operative therapy. There is a advancement in management of Metastasis tumors with Somatostatin analogs, Hepatic directed therapies, targeted therapies and Chemotherapies. The New target therapies with play an important in future management of advanced NET.
Reference:
1) Matthew H. Kulke et al, New treatment for advanced Neuroendocrine Tumors : American Society of Clinical Oncology 2011 Educational Book. 2011; 6: 137–142.
2) Kulke MH, Siu LL, Tepper JE, et al. Future directions in the treatment of neuroendocrine Tumors: consensus report of the National Cancer Institute Neuroendocrine Tumor Clinical Trails Planning Meeting. J Clin Oncol. 2011; 29:934–943.
84) Proceeding of the symposium on Approach to Neuro endocrine tumors of G.I. Tract in clinical practice
Pathology of Neuroendocrine Tumors of Gastrointestinal Tract Hype or a reality ?
R Pandey
Department of Pathology, SGPGIMS, Lucknow
Abstract
Neuroendocrine tumors of gastrointestinal tract have been usually understood as low-grade neoplasms with only a small potential for metastasis. It is now realized that their behavior may be very variable and some neuroendocrine tumors can behave as high-grade carcinomas. A large number of terms have been used to characterize these tumors over the years, like carcinoid, atypical carcinoid, neuroendocrine neoplasm and neuroendocrine carcinoma, etc. The European neuroendocrine tumor society has recommended use of the term neuroendocrine neoplasm followed by grade. The term neuroendocrine carcinoma is now restricted to grade 3 tumors. This has also been accepted by WHO in its 2010 classification.
The pathological diagnosis of a neuroendocrine neoplasm is easy in typical and well-differentiated cases, and is characterized by an organoid or diffuse pattern with nests or trabeculae of cells having variable degree of nuclear atypia and moderate to abundant granular cytoplasm. Although not considered essential for diagnosis, immunohistochemistry for synaptophysin and chromogranin is a useful adjunct, which may be essential for diagnosis in markedly atypical or poorly-differentiated cases. Diagnosis on endoscopic and small biopsies is not difficult when characteristic architectural and cytological features can be identified. However, in smaller samples, or in the presence of artifacts like crush artifact, immunohistochemistry is essential for diagnosis. Neuroendocrine pattern can be recognized on fine-needle aspiration cytology and a generic diagnosis of neuroendocrine neoplasm can be rendered. Preparation of cell-block from cytological material is helpful in demonstrating typical features and expression of neuroendocrine markers. Various other markers have been described for assessment of neuroendocrine neoplasms, but none has been recommended for routine clinical practice. Hormonal characterization by immunohistochemistry is not considered essential for diagnosis and management. Additional prognostic markers like Pax8, CK19, CD99, p27, cyclin E, and GLUT-1, etc., do not usually add to the information obtained from tumor type, grade and stage.
The current WHO grading system classifies neuroendocrine neoplasms in three grades on the basis of mitotic index and Ki67/MIB-1 index. Higher grade tumors also show increasing nuclear atypia and necrosis. Ki67/MIB-1 should be performed on all neuroendocrine tumors for grading as recommended by ENETS and WHO. TNM staging for neuroendocrine tumors is site-specific and follows the principles for tumors of digestive organs in general, and is based on tumor size and involvement of different layers of GIT. In general, the involvement of muscularis propria and serosa signifies increasing T stage. Combined risk stratification obtained by combining the data for grade and stage may also be useful for prognostication and therapy.
85) Surgery for primary tumors limited resections vs. radical surgery” what is the need of the hour?
Corresponding author:
Dr. Chandrakanth. Are MD, FRCS, FACS
Associate Professor
Division of Surgical Oncology
Department of Surgery/Genetics, Cell Biology and Anatomy
Program Director- General Surgery Residency
University of Nebraska Medical Centre
Omaha, Nebraska
USA. 68198
Phone: 402 559 8941
Fax: 402 559 7900
(Gastroentero-pancreatic Neuroendocrine tumours)
There is a noted increase in the prevalence and incidence of gastroentero-pancreatic neuroendocrine tumours worldwide over the last few decades. 1,2 It is not clear if this increase is real or if it is due to enhanced methods of detection and clearer diagnostic definitions. The 2010 WHO classification3 has provided a uniform platform for the diagnosis and staging of neuroendocrine tumours which has resulted in streamlined treatment strategies. In contrast to other malignancies, neuroendocrine tumours can run an indolent course. The management of neuroendocrine tumours is based on several factors such as location, functional status and extent of disease. Within the abdomen, the primary location of these tumours is either in the pancreas or gastrointestinal tract such as stomach, duodenum, small intestine, large intestine, appendix and rectum. In contrast to other malignancies, the symptoms associated with neuroendocrine tumours could be due to mechanical or biochemical causes attributed to abnormal hormone production. The extent of the disease can be defined as loco-regional or metastatic. The treatment is also influenced by the presence of multiple endocrine neoplasia I (MENI)
The mainstay of treatment for neuroendocrine tumours is surgery. The other treatment options include a) medical management (somatostatin analogues/chemotherapeutic agents such as streptozotocin/small molecules such as sunitinib and evorlimus/biologic agents such as bevicizumab), b) ablation, c) embolization and d) peptide receptor radionuclide therapy (PRRT). For localized disease surgery is the preferred treatment of choice. The treatment of patients with loco-regional or metastatic disease depends on the location and presence of symptoms.
Pancreas4,5: For localized disease surgery is the treatment of choice
Stomach4,5: The treatment approach varies based on the type (I, II or III) and the presence of MEN 1, size and number of lesions. Small tumours (<2 cms) can be resected by the endoscopic approach whereas larger tumours can be resected by the surgical approach.
Duodenum/small and large intestine5,6: The goals of treatment for localized disease are to resect the primary with associated lymphadenectomy. A cholecystectomy is performed and attempts are made to preserve the ileo-caecal valve.
Appendix5,6: The treatment is based on size, location, differentiation and involvement of mesoappendix. For lesions that are >2 cms, located at the base with intermediate to high grade features and involvement of the mesoappendix, a right hemicolectomy is recommended.
Rectum5,7: The treatment of rectal carcinoids depends on the size, extent of T stage and presence or absence of nodal disease. The treatment approaches range from endoscopic excision, transanal excision to anterior resection.
Metastatic disease1,4-7: For patients with metastatic disease, resection should be considered if up to 90% of the disease can be resected and the patients are fit for surgery. The other treatment choices for metastatic disease include, ablation, embolization, rarely transplantation, targeted chemotherapeutic agents such as sunitinib/evorolimus and PRRT.
It is well known that neuroendocrine tumours can run an indolent course and patients can live several years without any treatment. This needs to be borne in mind prior to planning a major procedure in elderly patients with favourable lesions. Lesions that are small and have a low mitotic rate and a low rate of Ki-67 expression can be observed as long as the pros and cons are discussed with the patient.
The rise in the incidence of neuroendocrine tumours will continue to influence the algorithms in the treatment approaches. It is essential that all these patients are managed in a true multi-disciplinary setting to provide the most optimal care based on the currently valid evidence.
REFERENCES:
1. Rindi G, Wiedenmann B. Neuroendocrine neoplasms of the gut and pancreas: new insights. Nat.Rev.Endocrinol. 2011;doi:10.1038/nrendo.2011.120
2. Bilimoria KY, Talamonti MS, Tomlinson JS et al. Prognostic score predicting survival after resection of pancreatic neuroendocrine tumours. Analysis of 3851 patients. Ann Surg 2008;247:490–500
3. Bosman FT, Carneiro F, Hruban RH and Theise ND. (Eds) WHO Classification of Tumours of the Digestive System 4th edn Vol.3 (IARC Press, Lyon, 2010).
4. NANETS Treatment Guidelines: Well differentiated neuroendocrine tumours of the stomach and pancreas. Pancreas 2010;39: 735–752
5. http://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf- accessed September 2011
6. Boudreaux JP, Klimstra DS, Hassan MM et al. Pancreas 2010;39: 753–766The NANETS consensus guidelines for the diagnosis and management of neuroendocrine tumours. Well differentiated neuroendocrine tumours of the jejunum, ileum, appendix and cecum.
7. Anthony LB, Strosberg JR, Klimstra DS et al. Pancreas 2010;39: 767–774The NANETS consensus guidelines for the diagnosis and management of gastrointestinal neuroendocrine tumours (NETs). Well-differentiated NETs of the distal colon and rectum.
86) Molecular imaging in neuro endocrine tumors have we made any progress?
Dr K.G.Kallur
Director Molecular Imaging HCG , Bangalore
Peptide Receptor Radionuclide Therapy (PRRT) is a form of molecular targeted therapy which is performed by using a small peptide (a somatostatin analog similar to octreotide) that is coupled with a radionuclide emitting beta radiation. PRRT is a novel nuclear medicine therapy (the first patients were treated in 1996) for the systemic treatment of metastasized neuroendocrine tumors. These types of tumors include gastroenteropancreatic tumors (so called GEP-NETs), e.g. arising from the small bowel (often called carcinoid tumors), the pancreas, duodenum or stomach, but also from the large bowel or the lung and many other tissues (so called diffuse neuroendocrine system). A handful of medical centers in Europe have been doing PRRT since the mid-1990s (including Basel, Milano, Rotterdam, and Bad Berka). These few centers now have 15 years experience administering PRRT. Now we have this facility in India at HCG Bangalore and AIIMS New Delhi.
This type of molecular radiation therapy can only be conducted on patients who have somatostatin receptor-positive tumors. Many, but not all, forms of neuroendocrine tumors express one or more somatostatin receptor subtypes. This means that when particular types of somatostatin analog drugs (most commonly octreotide) are brought in contact with the tumors, the receptors absorb the drug. When the drug (a small peptide of 8 aminoacids) is chemically bound to a form of radiation (the radionuclide), then the tumor absorbs both the chemical and the radiation. The emitted beta particles will then kill the tumors. The most effective radionuclides used at present are Lutetium-177 and Yttrium-90.
This makes PRRT a molecular targeted type of therapy, affecting those tumors with strong absorption of the radiation-laced peptide and affecting less or not, other tissue in the body. Precautions are taken prior to and during treatment to protect the kidneys from radiation damage since they are key to ridding the body of the administered radiation.
How Does PRRT Work
Perhaps the simplest way to explain the workings of PRRT is to think about the analogy of a magnet and its ability to attract iron shavings. Think of a neuroendocrine tumor with somatostatin positive receptors as the magnet and the iron shavings are a somatatostatin analog chemical (Octreotide) to which is bound or attached to some radioactive material (the radionuclide Y90 or LU177). The receptors in the tumors attract the octreotide and this chemical with the radioactive material is absorbed into the tumor by the receptor. The radiation then starts to kill the tumor cells.
This makes PRRT a form of targeted therapy, able to impact those tumors that can absorb certain types of chemicals bound to radioactive materials. Since the octreotide with the radionuclide is put into a patient’s blood stream, this form of therapy is systemic, reaching all parts of the body via the blood stream. This can be compared to a regional form of radiation-based therapy called microspheres / SirSpheres or Thereapshere that uses very small glass or resin beads that are impregnated with radiation. These beads are put directly into the blood circulating in the liver, using circulatory network in the liver to deliver the radiation to locations near each tumor.
Who Should Consider PRRT
Peptide Receptor Radionuclide Therapy (PRRT) will not work on all neuroendocrine tumors. For this treatment to work , the tumor MUST have somatostatin receptors. When a somatostatin analog (like a form of octreotide) is combined with a radionuclide such as Lutetium-177 (LU177) or Yttrium-90 (Y90), it has a strong affinity for the somatostatin receptor subtype-2 that can exist in the NET tumor. This means that the radioactive material put in the body for the treatment will be absorbed directly by the tumor with the receptor causing the tumor to die.
PRRT is considered to be a systemic form of treatment that will affect neuroendocrine tumors with receptors wherever they are in the body. This form of treatment is used primarily for patients with non resecatable tumors in multiple sites. Some patients only having tumors in the liver are treated with this therapy in order to reduce the size and number of tumors present in
the liver or other body areas in preparation for surgery.
In addition to needing somatostatin receptors in a patient’s tumors, many factors must be weighed before deciding to pursue this form of treatment. Certainly tumor load in terms of size, number and location of tumors is critical. Others could be age and physical condition. Recent (Kwekkeboom et. al. January, 2010) research on the use of Lu-177 octreotate for PRRT indicated that such treatment should be started early in the disease evolution.
What are the Risks?
As with most, if not all, of the treatment options open to neuroendocrine tumor patients, there are risks associated with using PRRT to treat metastasized tumors. The greatest risks arise from radiation toxicity affecting three things: 1) the blood system producing Red Blood Cells,White Blood Cells and Blood Platelets, 2) the functioning of the kidneys and 3) the functioning of the liver.
At one time kidney impairment or renal insufficiency was a significant risk, but as methods of protecting the kidney during PRRT became better refined, this risk has greatly diminished. Now, all medical centers administering PRRT take very specific measures to protect the kidneys using forms of amino acids infused before and after the treatment.
While specific protective measures have not been developed for the liver or for the blood system. Better control over radiation dosage helps to reduce toxicity from the radiation.
What are the Side Effects?
Each patient is different in terms of how they react to PRRT, but there are some side-effects that are more commonly and less commonly observed among patients. The duration of these side effects can vary greatly from a few hours to many days. Patients getting PRRT should probably consider having some medications on hand for nausea and pain to be taken on the return trip to their home. Typically if a patient expriences nausea, vomiting or pain during the actual administration of the PRRT, then medication is immediately provided to the patient.
The More Common Side-effects are:
Nausea
Vomiting
Abdominal discomfort or pain
Serious hematologic toxicity is extremely rare.
One example of PRRT : A case of Pancreatic neuroendocrine tumor with hepatic metatases.
Multiple SSR expressing hepatic metastases from pancreatic neuroendocrine tumor.
There is significant reduction in number as well as metabolic activity of the hepatic metastases after one dose of Lu177 Dotatate.