Natcon 2014

ER 001

PROSPECTIVE STUDY OF SOFT TISSUE SARCOMA

Dr Uday Chavan, M. Srinivasulu Dept. of Surgical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad-500004.

Email: dr_udaychavan@yahoo.co.in Mob: 9966430284

Aims: 1. To study the mode of presentation of Soft tissue sarcoma 2. To study the histological types 3. To study the stage of presentation 4. To study the surgical modalities used to treat these patients Methods: This study, study period is from August 2010 to December 2013. All Soft tissue sarcoma patients treated surgically at MNJ Institute of Oncology and Regional Cancer are included in this study. All cases were assessed clinically and diagnosed by biopsy MRI or CECT scan were done to assess local extent of tumor. For evaluation of metastasis CT-Chest was done. Other investigations were done depending upon individual symptoms. Patients were followed prospectively and the data and observation were collected on a proforma and analysed. Results: Lower limbs were the site of most soft tissue sarcomas in our present study. Our data is comparable with both Henrik et al⁴⁰ and Lawrence et al⁴⁵ both had lower limb as the site of maximum incidence. Even though there is a wide variation in the histology, Malignant Fibrous Histiocytoma is the most common histology. Surgery is the mainline of treatment. Most of our patients underwent wide excision and reconstruction when needed. Thirteen out of forty required amputation, making our amputation rate 32.5 %. The high rate can be attributed to late presentation and locally advanced nature of presentation of our patients. The high requirement of reconstruction in our present series can be attributed to the delayed and locally advanced presentation of our patients. Most Patients in our series presented at Stage III. All patients but two (5 %) had acceptable recover of limb functions. The high percentage of limb morbidity in our series may be due to our small sample size. Out of 40, 35 patients are on follow up and 2 had distal and 3 had local recurrences. This can be attributed to the small sample size of our study and small duration of follow up. Conclusion: Most patients present with swelling which is progressively increasing in size, Malignant Fibrous Histiocytoma being the most common histology. Majority of patients present with stage III disease and Wide resection with reconstruction, when feasible, provides acceptable local control and amputation may be required if the limb is not salvageable.

ER 002

GIANT SUBCUTANEOUS LEIOMYOSARCOMA OF ANTERIOR ABDOMINAL WALL - A CASE REPORT

Dr Sanghamitra Jena*, Dr Samir Bhattacharya + & Dr Shravasti Roy-

* + DNB Trainee, Department of Surgical Oncology,

Saroj Gupta Cancer Centre and Research Institute, MG Road, Thakurpukur, Kolkata-700063

Email: docsalu@gmail.com

Abstract: Subcutaneous leiomyosarcomas are rare tumor accounting for 1 to 2 % of all superficial soft tissue malignancies. Although they may arise anywhere in the body, they most frequently occur in the lower extremities. The incidence of subcutaneous LMS affecting the anterior abdominal wall is very rare. We herein report the case of a patient with a giant subcutaneous leiomyosarcoma arising in the anterior abdominal wall. On review of the English-language literature (PubMed, Medline), our case is found to be one of the largest tumors reported at this site. It was diagnosed by histopathology and immunohistochemistry and treated accordingly.

ER 003

SOFT TISSUE SARCOMAS: CLINICOPATHOLOGICAL STUDY OF 30 CASES:

Dr Jitin Yadav¹, Prof R G Baxla², Dr M Sarawagi³, Dr M Mundu⁴, Dr Sanjay Kumar Yadav¹, Dr Sumegha Rana¹, Dr Satish Kumar¹, Dr B M Baskey⁵

¹Junior Resident, Deptt. of General Surgery Rims, Ranchi, Jharkhand (INDIA)- 834009

Email: jitindrcool@gmail.com

AIM: We reviewed cases of soft-tissue sarcoma to gain insight into the presentation, treatments and outcomes for this rare disease and to determine various factors associated with outcomes. METHODS: This is a retrospective study of histologically confirmed cases of soft tissue sarcoma seen at Rajendra Institute Of Medical Sciences, Ranchi, over a period of 2 years between Jan 2012 and Dec. 2014. Data were retrieved from patients’ files and analyzed using SPSS computer software version 16.0 RESULTS: A total of 30 cases were studied. Male to female ratio was 4:1. Mean age of presentation was 46.5 ± 9.2 years. Most common site was lower limb (46.7 %) followed by upper limb (16.7 %). The vast majority of patients (56.7 %) presented with large tumors of ≥ 10 cm in diameter. Lymph node metastasis at the time of diagnosis was recorded in 23.3 % of cases and distant metastasis was present in 30 % cases. Liposarcoma (30.0 %) was the most common histopathological type followed by fibrosarcoma (23.3 %). Surgical excision was the most common surgical procedure performed in 76.7 % of cases. Surgical site infection was the most common complication in 43.0 % of patients. Local recurrence was noted in 16.0 % of cases. Mortality rate was 43.3 %. CONCLUSION: In conclusion, soft tissue sarcomas are aggressive tumor and has a high propensity for metastasis. Early diagnosis and complete excision of a small primary tumor is important in the treatment of soft tissue sarcomas.

ER 004

ROLE OF PROXIMAL MAJOR LIMB AMPUTATIONS IN THE ERA OF LIMB SALVAGE SURGERY

Prof. Dr. S. Subbiah. Ms, Mch., Asst prof. Dr. Sujay Susikar. Ms, Mch. and Dr. G. Arulkumar. Centre of Oncology, Government Royapettah hospital, Kilpauk medical college, chennai

Background: Extremity sarcoma is a heterogenous group of malignant tumors with less than 1 % incidence of all adult malignant tumors. In majority of the extremity sarcomas limb is salvageable. Amputations are being done for less than 5 % of patients with recurrent, large, high grade tumors or as a palliative procedure. Though amputations are shown to reduce local recurrence rate, that did not translate into improvement in overall survival. The role and therapeutic value of major limb disarticulation in the era of limb salvage surgery needs to be examined. Materials & Methods: Retrospective analysis of patient who underwent proximal limb disarticulation which includes fore quarter amputation, hind quarter amputation, hip & shoulder disarticulation at our centre between the period 2007 to 2013 was done using patients record, follow up details were gathered. RESULTS & DISCUSSION: Proximal major limb amputation was done in 15 patients out of 473 patients, which constitutes less than 3 % of extremity sarcomas treated at our centre. Hip disarticulation (n = 5), forequarter amputation (n = 3) humerus disarticulation (n = 2) hind quarter amputation (n = 5). Majority of the tumors were high grade & large tumor (size greater than 10 cm). All of them had uneventful post operative period, In most of them quality of life improved after amputation. Proximal limb amputation of extremity sarcoma is becoming rare and most often done for recurrent, high grade tumors with major neural & vascular involvement where restoring a functional limb is not possible and as a palliative procedure to improve quality of life. CONCLUSION: Proximal major limb amputation appears to have a role in selected minority of patients with extremity sarcoma as a curative treatment and also as a palliative procedure with respect to symptom control and improvement in quality of life.

ER 005

AN OUTCOME ANALYSIS OF GIANT CELL TUMOR OF RADIUS A SINGLE INSTITUTIONAL EXPERIENCE OF SIX CASES

Dr. Subbiah Shunmugam, Sujay Susikar, S. Deepa, Center for Oncology, Department of Surgical Oncology, Government Hospital Royapettah, Kilpauk Medical College, Chennai.

Introduction Giant cell tumor (GCT) is an aggressive potentially malignant tumor usually located in the epiphyseal end of long tubular bones especially distal femur, proximal tibia and distal radius. GCT of radius represents 10 % of GCTs involving bone. We present our experience with giant cell tumor involving the radius. Materials and Methods Based on retrospective analysis of data collected during the period of 10 years from 2005 to 2014, we had six cases; Functional outcome was assessed using the revised musculoskeletal tumor society score. Results Of the six patients analyzed there were 3 males and 3 females. The mean age of patients was 31.1 years (range 21–42 years). All 6 patients were of Campanacci grade II/III. Five patients were managed with wide excision of tumor and reconstruction with ipsilateral non-vascularised fibular graft and one patient with GCT of proximal radius managed with wide excision without reconstruction. Mean follow-up period was 3.9 years (3–4.5 years). There were no patients with graft related complications. One patient who was a case of recurrent GCT developed tumor recurrence and was treated with below elbow amputation. The mean Revised musculoskeletal tumor society score was 91.48 % (good). Discussion Wide excision was done in all six cases because of extensive cortical involvement (>50 %) and articular surface involvement with good functional outcome. The surgeon needs to strike a balance between reducing the incidence of local recurrence while preserving maximal function. Conclusion The procedure of non vascularised fibular autograft reconstruction of distal radius show ubstantial loss of function as compared to normal wrist, it still gives subjective results acceptable to most patients and comparable to all other methods of reconstruction. Thus, non-vascularised fibular auto-graft reconstruction arthroplasty of distal radius can be considered as a reasonable procedure after en bloc excision of Grade II/III GCT

ER006

RESECTION OF BONE TUMOURS OF PELVIS – AN INSTITUTIONAL EXPERIANCE

Dr. N. Selvaraj ¹, Sujay Susikar, R. Rajaraman³

²Head, Centre for Oncology and Professor of Surgical Oncology, Centre of Oncology, Government Royapettah Hospital, Kilpauk Medical College, Chennai-14,

Introduction: Bone tumours arising in the pelvis are difficult to treat. Historically they were managed with total limb ablation. Limb salvage procedure with wide margin of resection is difficult. But it provides a useful limb with better quality of life. Aim: To analyse the outcome of various pelvic bone tumours managed with surgery and functional outcome of type II internal hemipelvectomy without prosthesis reconstruction. Method: A total of 17 patients were treated for pelvic bone tumours at Center for Oncology Govt. Royapettah Hospital from year 2003 to 2014. The pathology were chondrosarcoma (n = 10), giant cell tumour (n = 2) PNET pelvis (n = 3), aneurysmal bone cyst (n = 1), hemangioendothelioma (n = 1). These patients underwent internalhemipelvectomy without prosthesis reconstruction in our department type I (n = 8), Type I and II (n = 4) Type II (n = 1), type II and III (n = 4). The records were analysed regard the duration of surgery, blood transfused, length of hospital stay, post-operative complications and functional outcome assessed using the Musculoskeletal Tumor Society Scoring system. Conclusion: Internal hemipelvectomy is a viable option for pelvic tumours. Type II Internal hemipelvectomy without prosthesis has comparable surgical and functional outcome with prosthesis reconstruction of pelvic tumours. Mean functional score based on Musculoskeletal Tumor Society Scoring System, was good in 5 patients, fair in 2 patients and poor in 2 patients which are comparable with other studies with prosthetic reconstructions.

ER 007

Primary Extraosseus Ewing sarcoma of abdominal wall- a rare entity

Dr Channabasappa kor¹ Dr Sameer Gupta², Dr Vijay kumar³, Dept of surgical oncology, King George medical college, Lucknow

Abstract: Ewing sarcoma is malignant round cell tumour that primarily affects bones. Primary Extrosseous Ewing sarcoma [EES] is extremely rare. Clinical and radiologic features are non specific. Diagnosis is mainly based on immunohistochemistry. This article presents a rare case of Primary extrosseous soft tissue Ewing sarcoma of right antero-lateral abdomen wall in a 30 year old lady and was successfully treated with multi agent chemotherapy and local treatment in the form of aggressive surgery and radiation.

ER 008

Soft tissue neoplasms: Our experience from a tertiary care center

Amitabh Jena¹, G V Sivanath reddy², S Raja Sundaram³, Banoth Manilal⁴,Amarchala Yadagiri Laskhmi⁵, Rashmi Patnayak⁶

Institutions:

¹Additional Professor, Department of Surgical oncology, Sri Venkateswara Institute Of Medical Sciences, Tirupati, Andhra Pradesh-517507, Cell No. +91- 9493547746, Fax no. 0877-2286803

E-mail-dramitabh2004@yahoo.com

Aim: To analyze various soft tissue neoplasms encountered in our center and correlate with various clinicopathological parameters. Methods: We have analyzed all the soft tissue neoplasms which were surgically resected during the study period from June 2007 to May 2012. The type of surgery was mainly based on pre-operative imageological and biopsy findings. Results: There were 47 soft tissue neoplasms in the study period. Out of these 37 cases were malignant and 10 cases were benign. The mean age of patients was 43.87+/−18.04. There were 30 males and 17 females in the study group. The most common location was lower extremities. Other sites include upper extremity, retroperitoneum and trunk. The surgical procedures performed were mainly excision of the tumour like wide excision, compartmental excision etc. Conclusion: In our study group, the most common soft tissue tumor was malignant fibrohistiocytoma.

ER 009

Preservation of Anterior Tibial vessels in limbsalvage surgeries for tibial tumor – Is it oncologically safe or useful?

Dr Balasubramanian V¹, Dr. Kathiresan narayanaswamy², Dr. Anand Raja³, Prof. Mayil Vahanan Natarajan ⁴, Department of Surgical Oncology, Cancer Institute (WIA), Chennai, nkathiresan@yahoo.com, 9840063890. Email - balapsgimsr@gmail.com,

Aim To assess the oncological safety, functional outcomes in patients who have anterior tibial vessels preserved during limb salvage surgery with custom made prosthesis for proximal tibial tumours Materials and Methods A retrospective analysis of 76 consecutive patients who underwent limb salvage surgery with custom made prosthetic reconstruction for proximal tibial tumors between 1998 and 2011 at our institute, were included. The mean circumference of the leg at 15 cms above the medial malleolus measured at the 1st year follow up was compared with the opposite limb. The analysis was done using SPSS 17.01 and the functional outcome was analysed using the MSTS functional score. Results Of the 76 patients, 52 (68.4 %) were males and 24 (31.6 %) were females. Osteosarcoma was found in 62 (81.5 %) patients, 1 had leiomyosarcomas, 1 patients had chondrosarcomas 3 had ewings sarcoma and 9 patients had giant cell tumor of the bone. There were 3 local recurrences in the anterior tibial vessels ligated arm vs 1 local recurrence in anterior tibial vessels preserved arm. The overall survival and disease free survival at 5 years were 75 and 70 % respectively. There was no statictical difference in survival between the anterior tibial preserved and ligated arms. The data on circumference of leg measured at 15 cms above the medial malleolus at 1 year follow up was available for 29 patients (17 in ligated vs 12 in preserved arm). There was no statistically significant difference in the quality of life and functional outcome between these groups. Conclusion Anterior tibial vessels can be safely preserved in a selected group of patients with low volume disease around proximal tibio-fibular joint without compromising the oncological safety and functional outcome.

ER010

Epidemiological Trends of Oral Cancer in Elderly Patients: A study of tertiary care centre in North India.

Mahendra Pratap Singh,^* Sanjeev Misra^#, MLB Bhatt^$, Vijay Kumar^*,

^* Department of Surgical Oncology, King George’s Medical University, Lucknow, UP, India-226003. Email: drvkumar2007@gmail.com Email- mahendrasingh113@gmail.com Mobile number: 09532-002616.

Methods: A retrospective evaluation of 658 oral cancer cases was conducted in the Department of Surgical Oncology, King George’s Medical University, Lucknow, India, over a period of 4 years from 2010 to 2013. Cases of 60 years or above were considered as elderly. One hundred sixty-two elderly patients were eligible for study. Age, sex, tobacco habit and clinical stages at presentation of cases were recorded. Findings were formulated and statistical evaluations were done. Results: This study comprised of 162 oral cancer cases with mean age of 65 years. There were 107 males (66 %) and 55 females (33.9 %). Majority of cases were in 7th decade (89 %) followed by 8th (6 %) decade of life. Alveolus (43 %) was major site of infliction of carcinoma followed by buccal mucosa and gingivobuccal sulcus. Smokeless tobacco was major form of tobacco consumption (62 %) followed by both smoked and smokeless (25 %). Fifty-seven percent patients were diagnosed at advanced stage of disease. Conclusion: Carcinoma developed mostly in 7th and 8th decades of life. Alveolus was major affected site followed by buccal mucosa and gingivobuccal sulcus, which is attributable to use of smokeless form of tobacco. Smokeless tobacco consumption was the major form of tobacco consumption. Most of the cases of carcinoma were diagnosed at advanced stage. Advanced stage of disease, poor health and old age increases the burden of disease and worsens the prognosis. To provide quality of life to elderly, there is need to provide timely checkup and early diagnosis of oral cancer especially in the tobacco users. It will reduce disease burden and improve prognosis.

ER011

CLINICAL ROLE OF MICRO RNA (miRNA) EXPRESSION PROFILES IN ORAL SQUAMOUS CELL CARCINOMAS

Rajkumar Kottayasamy Seenivasagam¹, Rajaraman Ramamurthy¹, Munirajan Arasambattu Kannan², Subbiah Shanmugam¹, Deva Magendhra Rao²

¹ Department of Surgical Oncology, Centre for Oncology, Kilpauk Medical College & Govt. Royapettah Hospital, ² Department of Genetics, Dr. ALM PG Institute of Basic Medical Sciences, University of Madras, Chennai, India

Introduction: MicroRNAs (miRNAs) are endogenous, small non coding RNAs involved in essential biological functions of the cell. They may play a crucial role in tumourigenesis by differential expression in cancer cells. Varied expressions of miRNAs’ in oral cancers have been reported, some showing strong clinical associations to warrant further investigation. The present study is an analysis of miRNAs expression profiles and their association with clinical characteristics of oral cancer patients. Patients and Methods: The study included analysis of 4 select miRNAs (miR - 21, 125 b2, 184 and 138) Expression Profiles in 36 oral cancer patients and their impact on the epidemiological and clinical characteristics of these patients. The study was a Prospective collaborative clinical and molecular research study done between 2011 and 2013. Tumour tissue samples from biopsies and surgical specimens were collected processed and miRNA expressions were determined using Taqman® RT-PCR. Clinical and epidemiologic data were compared with the above using SPSS 16® (IBM Inc, USA) and EXCEL 2007 ® (Microsoft, USA). Results: MiR-138 down regulation was seen significantly higher in younger patients (P = 0.02, 46.6 vs. 58.4 years). MiR-184 was significantly up regulated in nontongue oral cancers (P = 0.035, 17 vs. 11 patients). MiR-125b2 was significantly down regulated in alcoholics (P = 0.02, meanRQ = 0.12 vs. 0.37). MiR-21 was significantly down regulated in patients with good response to chemoradiotherapy (P = 0.05, meanRQ = 0.83 vs. 1.52) and in high grade tumours. Conclusion: MiRNAs altered expressions have definite and significant associations with many clinical and epidemiological characteristics of oral cancer patients. Development of newer, simpler, more efficient, safer and cost effective techniques for storage, transportation, extraction and analysis of RNA is the need of the hour. Further studies involving multiple panels of miRNAs are needed to provide conclusive evidences and to influence their management.

ER012

Extent of Surgery in Malignant Parotid Tumors.

Dr. Shahnawaz M.

Consultant Surgical Oncologist, Katihar Cancer Care Centre, Assistant Professor of Surgery, Katihar Medical College & Hospital. Postal address: Rampara, Katihar-854105, Bihar, Mob: 8521120962

Email: shahnawazmuslim@yahoo.com

Introduction: About 70-80 % of salivary gland neoplasm arises in the parotid, out of which 20-25 % are malignant. Mainstay of treatment for a malignant parotid tumor (MPT) is surgery. But, Objective of the study: What should be the extent of surgery? It depends upon histological type, grade and stage of tumor. It may vary from mere incisonal biopsy to radical resection. An incisional biopsy is indicated in cases where the tumor is extensive and cytology shows features of malignancy or in cases where lymphoma is suspected, so that, further characterization of tumor and proper treatment planning can be performed Materials & Method: Minimum definitive surgery for a MPT is superficial parotidectomy. It is indicated in cases where tumor is small, low grade and confined to superficial lobe only. Surgical option for most other cases includes total conservative parotidectomy, total parotidectomy with sacrifice of facial nerve, radical parotidectomy and neck dissection. Whether to preserve the facial nerve or not, depends upon presence/absence of pre-operative facial nerve involvement and the plane of dissection between tumor and nerve. If the facial nerve is not involved and a plane of dissection can easily be developed between the tumor and nerve, the nerve can be preserved; else, it needs to be sacrificed. Restoration of function of facial nerve can be achieved by putting a graft of great auricular nerve between stump of main trunk and its branches. More extensive tumor involving skin and surrounding structure needs radical parotidectomy. Conclusion: Neck dissection is indicated in all clinically N+ neck. A prophylactic neck dissection in clinically N0 neck is needed in cases where the risk of nodal metastasis is high, as in cases of high grade mucoepidermoid carcinoma, carcinoma-ex-pleomorphic adenoma adenocarcinoma NOS, undifferentiated carcinoma and squamous cell carcinoma. Extent of surgery in an accidentally diagnosed MPT after superficial parotidectomy varies from observation for a small low grade tumor where surgeon is confident of adequate clearance to more aggressive approach for a large, high grade tumor.

ER 013

EVALUATION OF OUTCOME AND THE INCIDENCE OF LARYNGOESOPHAGEAL DYSFUNCTION IN T3 LARYNGEAL AND HYPOPHARYNGEAL MALIGNANCIES TREATED BY CHEMORADIATION- AN INTERIM ANALYSIS.

Santhosh Kumar N, Regional cancer Centre, trivandrum, kerala, India

Introduction: The primary objectives of laryngeal or Hypopharyngeal cancer treatment are cure, long-term survival, and the preservation of a functional larynx. Larynx preservation should essentially preserve both the function and the structural ability for the functioning. When concurrent chemoradiation or even radiation offered to the patient in justification of laryngeal preservation, there have been reports of post radiation sequalae causing microaspirations, dysphagia, chondroradionecrosis, and structural edema causing varying degrees of airway or esopharyngeal obstruction, altered voice and other local events. Whether these above said sequelae are a part of disease progression or failure of chemoradiation to reverse such events or freshly induced or aggravated by chemoradiation is very unclear. Laryngo-esophageal dysfunction free survival (LEDFS) includes death, local recurrence, total/partial laryngectomy, tracheostomy more than 2 years, or feeding tube more than 2 years. Objectives: Prospective analysis of the patients with T3 Laryngeal and Hypopharyngeal squamous cell carcinoma who underwent chemoradiation treatment in our institute. The specific objectives were to assess the locoregional response at 12th week and to analyse the factors influencing the remission or residual disease status after the curative treatment. The incidence of Laryngoesophageal dysfunction in these patients were also analysed. Materials and methods: All patients diagnosed as T3 (N0- N2) Laryngeal or Hypopharyngeal squamous cell carcinoma were included in the study. Demographic details, Disease parameters, treatment details, treatment response, residual disease and salvage treatment were recorded for every patient. The features of laryngo oesophageal dysfunction like aspiration, speech and swallowing problems were also recorded. All the patients were followed up for a minimum of 1 year. Results: A total of 31 patients with T3 laryngeal or hypopharyngeal carcinoma treated by chemoradiation were screened and recruited. Fourteen patients (45 %) were disease free and are being regularly followed up till date. Seventeen patients (54.8 %) had varying degrees of edema and post radiation changes at the primary site. Of these two patients were tracheostomised during treatment and retained still on tracheostomy and two are retained on feeding tube due to aspiration problem. one patient has respiratory distress, maintained on low dose steroids as he is unwilling for a tracheostomy. Three (9.6 %) had persistent ulceration at the primary site but the biopsy were negative for both. So they were diagnosed as chondroradionecrosis and are being closely followed up by endoscopies to rule out disease as they are symptom free. Conclusion: The interim results of our study showed a complete remission as well as functional organ preservation in 45 % of patients. More than half of the patients have post radiation sequalae such as structural edema, microaspirations, dysphagia and chondroradionecrosis which lead to Laryngo-esophageal dysfunction. Our clinical study certainly will throw light on the Laryngo esophageal dysfunction at future follow up and further analysis. With consistent methodologies, clinical trials can more effectively evaluate and quantify the therapeutic benefit of novel non surgical treatment options for patients with locally advanced laryngeal and hypopharyngeal cancer.

ER 014

Efficacy of frozen section in evaluation of depth of tumour invasion of early squamous cell carcinoma of tongue

Dr Nebu Abraham George, Dr Anila K R, Dr Sreekanth S Kumar, Dr Balagopal P G, Dr Shaji Thomas, Dr Bipin T Varghese, Dr Elizabeth Mathew Iype, Dr Paul Sebastian, Assistant professor, Department of surgical oncology, Regional Cancer Centre, Trivandrum 695011, georgeabe@gmail.com, 9447020522

Aims:

1. To determine accuracy of frozen section in measuring depth of invasion of the primary tumour.

2. To determine the correlation between depth of invasion of the primary tumour measured by frozen section and the pathological neck nodal status.

Methods: Prospective study of 63 patients at Regional Cancer Centre, Thiruvananthapuram with cT1- T2 N0 M0 squamous cell carcinoma of the oral tongue who underwent wide excision of the primary tumour and an extended supraomohyoid neck dissection clearing neck node levels I – IV. The excised tongue specimen was sent for frozen section analysis. The margins of excision and depth of tumour invasion was recorded. The wide excision and neck dissection specimen was then sent for routinehistopathological examination. Apart from the routine parameters the depth of invasion of tumour on final histopathology report was correlated to the depth of invasion on frozen section. Results: In the 63 cases the male: female ratio was 47:16. Median age was 52 years. The depth of invasion on frozen section matched the depth of invasion on final HPR in 49 cases; frozen section overestimated the depth of invasion in 6 cases and underestimated the depth in 8 cases. The coefficient of correlation between the 2 depths was 0.96. Lymph node metastasis in the neck dissection specimen was not seen in any specimen in which depth of invasion on frozen section was less than or equal to 3 mm. Conclusion: Frozen section is an accurate method to assess depth of invasion of squamous cell carcinoma of the tongue. The depth of invasion is a useful predictor of the presence of occult nodal metastasis in clinically N0 neck.

ER 015

A review on our experience on reconstruction of maxillectomy defects, surgical complications and Outcomes

Amrutha VRS*, Ganesh MS**, Uday karjol*, Sriphani C*, Ajay CV*,Vasureddy C**, Sangireddy N** Department of Surgical Oncology, Vydehi Institute of Medical Science, Bangalore 66, Karnataka, India.

Aim: To evaluate the complications and outcomes following various reconstructive methods following various forms of maxillectomies Methods: We performed a retrospective analysis of medical records of patients who underwent various forms of maxillectomies from Jan 2011 to dec 2013. Postmaxillectomy defects were managed by either prosthesis or local flaps. Results: Forty patients had underwent various forms of maxillectomies. Fifteen patiens had undergone Browns class 1a maxilectomy as a component of gingivobuccal cancers extending to upper alveolus wherein a bite resection was performed. All of these patients underwent reconstruction with Pectoralis major myocutaneous flap. Ten patients underwent class 2a maxillectomy wherein they underwent reconstruction with Obturator and Split skin thickness grafting. Nine patients underwent class 3a-b resection and reconstruction with Temporalis myofascial flap reconstruction. Four patients underwent class 4a-b resection and reconstruction with temporalis myofascial flap. Two patients underwent Orbitomaxillary resection with palate preserved and reconstruction with temporalis myofascial andforhead flap. Two patients who underwent orbital exenteration developed nasocutaneous fistula which were reconstructed with forehead flap. One patient had partial loss of temporalis flap, one had postoperative epiphora due to ectropion which were managed conservatively. Mean follow up period was 8 months (Range 6–24 months). Two patients developed moderate grade of trismus after completion of radiotherapy. One patient developed recurrence in neck after 6 months of completion of adjuvant radiotherapy. All had moderate to fair speech and eating function. Conclusion: There was no difference between flap reconstruction or obturator intervention of maxillary defects in speech and eating function. Small and lateral defects are better reconstructed with obturator and defects involving orbit and total maxilla are better reconstructed with flaps.

ER 016

Utility of Intra operative Frozen Section as a decision making tool in Thyroid nodules with Indeterminate Fine Needle Aspiration Cytology

Dr. Siva Ranjith¹, Dr. Nebu Abraham George² Dr. Anila K R³, Prof. Paul Sebastian⁴, Division of Surgical Oncology, Regional Cancer Centre (RCC) Trivandrum, ph: 09895234986; email: sivaranjith.j@gmail.com

Introduction Surgical treatment decisions in cases of thyroid nodules are usually made based on Fine Needle Aspiration Cytology (FNAC). There are occasions wherein FNAC is inconclusive and the nodule is clinically or radiologically suspicious for malignancy. The role of frozen section for an intra-operative pathological diagnosis of malignancy in a thyroid nodule at the time of hemi-thyroidectomy, thus avoiding a second surgery, is still a controversy. Aim To assess the utility of intra-operative frozen section biopsy for diagnosing malignancy in thyroid nodules, which are clinically suspicious for malignancy and inconclusive on FNAC. Methods Thirty patients with solitary nodule of thyroid which were clinically or radiological suspicious for malignancy, who had indeterminate FNAC on pre-operative evaluation and planned for hemithyroidectomy from 2010 to 2013, at Regional Cancer Centre Thiruvananthapuram, were studied. Frozen section examinations were tried to aid in the intraoperative diagnosis and change the surgical plan intraoperatively, if the frozen section was diagnostic of malignancy. The correlation of frozen section with the final histopathology, and the impact of frozen section diagnosis on intra-operative decision taking were determined. Results Of the thirty patients, six (20 %) were males and 24 (80 %) were females, with a mean age of 37 years. The overall correlation of frozen section with the final histopathology was 30 % (9/30 cases). Four of the thirty cases (13 %) were diagnosed as malignancy by frozen section, there by altering the treatment plan from hemithyroidectomy to total thyroidectomy. But in the final histopathological analysis there were 16 malignancies altogether, out of which only 4 (25 %) were correctly diagnosed by intraoperative frozen section. In 53 % (16/30) of patients, the frozen section diagnosis was follicular neoplasm/lesion, and hence did not have an impact on the intra-operative decision making. Conclusions Intra-operative frozen section for diagnosing malignancies has a low correlation with the final histopathology and did not have significant impact on intra-operative decision making.

ER 017

Title: Neoadjuvantchemoradiation Vs Primary sugeryin T4 resectable oral cavity lesions

Ajay Chanakya. V¹, Ganesh M.S², Sushmitha. C³, Sriphani. P⁴, Uday. K⁵, Amritha. P⁶, Sangi Reddy. N⁷, Vasu Reddy. C⁸

Department of Surgical Oncology, Vydehi institute of medical sciences, #82, EPIP area, Whitefield, Bengaluru-560066.

Aim: To evaluate role of neoadjuvant chemoradiotherapy in T4 resectable oral cavity cancers in comparison to primary surgery with respect to better margin status, extent of resection and reconstruction, organ preservation and morbidity Methods: A prospective comparative study was performed over last 1 year. Ten patients of operable T4 oral cancers underwent the Neoadjuvant chemoradiotherapy with 4600 cGy of teleradiotherapy delivered in 23 fractions along with concurrent Inj. Cisplatin on day 1 and 21 and evaluation was done before patients were taken up for surgery after 3–4 weeks. In the same period 15 patients of T4 disease underwent surgery followed by adjuvant chemoradiotherapy/radiotherapy. The two groups were compared with respect to response to chemoradiotherapy in neoadjuvant arm, margin status, morbidity and mortality. Results: Of 10 patients in Neoadjuvant arm 7 were female and 3 were male. Nine patients had partial response following chemoradiation, one patient had progressive disease. Of the 9 operated, 2 underwent wide excision while others underwent composite bite resection. Following resection, 5 patients underwent reconstruction using PMMC flap, one bipedal PMMC and another with both PMMC and DP flaps. Postoperative histopathology was found to be squamous intraepithelial neoplasia in two patients. Margin positivity is noted in two patients. Delayed wound healing is the most common postoperative complication. Postoperative mortality is noted in one patient due to pulmonary complications. Of 15 patients who underwent upfront surgery, 7 were female and 8 were male. All 15 patients underwent composite resection. Reconstruction, 13 underwent using PMMC flap and two by bipedal PMMC flap. Median follow up period was 6 months (range 6–18 months). One case who underwent upfront surgery had local recurrence which was treated with re-excision and reconstruction with forehead flap. Conclusion: Interim results show that neo-adjuvant treatment helps in downsizing and decrease the extent of resection inresectable T4 oral cavity lesions in a small group but may be associated with delayed wound healing. The study is an ongoing one and a larger study size would give relevant information.

ER 018

Nasolabial Flap reconstruction for defects of Oral cavity and Nose cancers

Vamsidhar. P, Vijay Kumar, Sameer Gupta, Naseem Akhtar, C.G. Kori, Nilesh Jain

Resident, Dept of Surgical oncology, King George Medical University, Lucknow, 226003, INDIA.

Aim: Reconstruction of various defects of oral cavity and nose using Nasolabial Flap. METHODS: A retrospective analysis of 32 cases of oral cavity and 1 case of carcinoma nose where the defect created by primary excision of tumor is reconstructed by Nasolabial Flap was carried out. Results: Good cosmetic and functional outcome. It can also be used for reconstructing small defects of Nose. There was no flap necrosis, one patient had a small oro cutaneous fistula which was healed over 2 weeks of time and two patients had wound dehiscence. Conclusions: Nasolabial Flap is a reasonable alternative to pectoralis major myocutaneous flap for small to moderate size defects of oral cavity with good cosmetic and functional outcome. It can also be used for small defects of Nose.

ER019

Tongue Flap reconstruction for defects of Buccal mucosa and retromolar trigone (RMT)

Naseem Akhtar, Vijay Kumar, Sameer Gupta, Vamsidhar. P, C.G. Kori, Nilesh Jain Dept of Surgical oncology, King George Medical University, Lucknow, 226003, INDIA.

Aim: Reconstruction of defects of Buccal mucosa and RMT using Tongue Flap. Methods: A retrospective analysis of 21 cases of oral cavity where the defect created by primary excision of tumor is reconstructed by Tongue Flap was carried out. Results: Good functional outcome. There was no flap necrosis, two patients had l oro cutaneous fistula which were healed over 2 weeks of time, there was no significant difficulty in speech. Conclusions: Tongue Flap is are liable flap for small defects of buccal mucosa and RMT with good functional outcome.

ER 020

Prophylactic central compartment dissection in T3 and T4 papillary thyroid carcinoma, is it really needed ?

Than singhTomar, Dr. Nebu Abraham George, Dr. Paul Sebastian, Division of surgical oncology, Head and Neck services, Regional Cancer Centre (RCC), Medical College Campus, Trivandrum -11 Email - thansinghtomar111@gmail.com, psebastian2091@gmail.com

Background –American Thyroid Association guidelines 2006 for Differentiated Thyroid Cancer recommended prophylactic central compartment neck dissection (pCCND) (category B). Subsequent ATA revision in 2009 recommended pCCND in T3 and T4(Category C). Whether pCCND should be performed in all patients with clinically node negative PTC is controversial, as there are no prospective randomized trials or other high-level evidence to guide decision making. Since pCCND is associated with increased chances of recurrent laryngeal nerve paralysis and hypocalcaemia with doubtful minimal benefits, and the role of pCCND is questionable. Objective– The Primary objective of the study was to detect rate of local nodal relapse in papillary carcinoma thyroid (T3 and T4) treated with total thyroidectomy alone. Materials and Methods– Retrospective analysis of patients with T3 and T4 papillary thyroid cancer without neck nodal disease (clinical, imaging and intraoperative findings), treated with total thyroidectomy alone +/− postoperative radioactive iodine during period of 01/01/2010 to 31/12/2012 at Regional Cancer Centre Thiruvanathapuram, Kerala, India. Results– Of the total 77 patients, 54 were female and 23 were male. Average age was 43 years. Average follow up was 34 months. Fifty-eight (75 %) patients had extra thyroidal spread (T4) and 19 (25 %) patients were T3. 19 (24.6 %) had surrounding muscles or organ infiltration. Twenty (26 %) patients had high risk histologies. Forty-four (57 %) patients received postoperative radioiodine. Only 2 (2.6 %) nodal recurrence were recorded. Four years disease free survival and overall survival probability were 78.2 and 98.7 % respectively. Conclusions - Neck nodal recurrence rate was low in patients without pCCND and these rates are comparable with other published data with pCCND. Role of pCCND is limited and long term follow up with a bigger patient cohort is needed for a definite conclusion.

ER021

A COMPARISON BETWEEN SUBJECTIVE AND OBJECTIVE ASSESSMENT OF FUNCTIONAL OUTCOME OF PATIENTS AFTER ORAL CANCER RESECTIONS

Aim The aim was to correlate the subjective and objective assessments of the functional outcome in patients after oral cancer resections and study factors influencing the functional outcomes after therapy for oral cancers. Methods A proforma was used for initial data collection and the patients were assessed preoperatively, 6 months and 1 year after treatment for the following parameters which includes pain, mouth opening, oral competence, occlusion, speech, swallowing, social acceptance. This is done by using “Royapettah Scoring System” devised in our institution which assesses the above said parameters. Except for pain and social acceptance, other parameters were assessed objectively as well. Results Fifty-one patients were included in the study. Sixty-seven percent were males (n = 34) and 33 % were females (n = 17). The subsites included buccal mucosa (n = 18) followed by tongue (n = 16), alveolus (n = 8), lip (n = 3), retromolar trigone (n = 3), floor of mouth (n = 2) and hard palate (n = 1). Except for the pain and social acceptance, other parameters were assessed with subjective and objective methods and compared using the assessment data at 6 months post treatment. There was no difference between the two assessment methods in terms of statistical significance and are found to correlate well with each other. Factors influencing the postoperative functional outcomes include subsite affected, radiotherapy, extent of resection, mandible resection and type of reconstruction. Conclusion In our study, subjective and objective assessment methods correlated well with all the parameters except for swallowing where more qualitative data regarding the nature of the impairment was obtained from objective studies which further aided in tailoring appropriate rehabilitation measures.

ER022

Medullary Thyroid Cancer: A Retrospective Analysis of a Cohort Treated at a Single Tertiary Care Centre Between 2008 to 2012.

¹Dr. Kailash Ramrao Surnare, Dr. Nebu Abraham George, Dr. Paul Sebastian, Division of surgical oncology, Head and Neck services, Regional Cancer Centre (RCC), Medical College Campus, Trivandrum -11 Email- kailashsurnare@gmail.com, psebastian2091@gmail.com

Introduction: Medullary thyroid carcinomas (MTC) constitute about 5 to 7 % of thyroid neoplasms. Approximately 75 % are sporadic and 25 % are inherited. MTC has a 40‑50 % 10-year survival rate. Aim and Objective: The aim of this study is to examine clinical aspects, surgical management and long term survival of patients with medullary thyroid carcinoma. Materials and methods: This is a retrospective analysis of the cases diagnosed as Medullary Thyroid Carcinoma (MTC) in Regional Cancer Centre, Trivandrum, Kerala, India over a period of 5 years (2008–2012). A total of 22 cases were accrued. The demographic data, clinical details and the treatment modalities were studied. The period of follow-up ranged from 1.8 to 5.6 years. Results and discussion In this study out of total 22 patients male to female ratio was 12:10. None had family history. Type of surgery were total thyroidectomy(TT) with neck dissection(ND) in 13 patients; completion thyroidectomy with ND in 4 patients and TT alone in 5 patients. External Beam Radiotherapy (EBRT) was given in 4\22 (18 %) because of extra thyroidal spread or extra capsular spread. Six (27.2 %) patients had subsequent nodal recurrence, all six patients had raised calcitonin level after initial surgery in spite of no macroscopic or radiologic disease, they all had salvage surgery and all of them were advised EBRT but one refused. Three (13.6 %) patients had distant metastases of which one patient died after 18 months. The 5 year overall survival probability was 85.5 % and disease free survival probability was 76.7 %. Conclusion: Our Survival outcome is comparable to other international studies. Persistent elevated serum calcitonin levels correlated with loco regional and distant metastases.

ER023

Prognostic implication of the depth of invasion in oral carcinoma: retrospective analysis

Trehan S S, Tadayia M, Yadav D, Shukla H K

GCRI Ahmadabad Gujarat

Background: oral carcinoma is considered to be loco regional disease which metastasizes to nodal and distant sites. Prognostic factors include size of tumor, nodal status and various pathological factors. Depth of invasion has been suggestive to have a relationship with the occurrence of cervical metastasis. The aim of this study is to analyze the prognostic implication of tumor depth for oral cavity carcinoma. Methods: all patients who were operated for oral carcinoma at gcri from July 2011 to December 2011 were analyzed. Retrospective data review was done to assess the prognostic factors for locoregionl and distant metastasis. tumor depth, margin status, differentiation, perineural invasion, LVI was analyzed. DFS, recurrence were analyzed and correlated with the depth of invasion. Results: total no patients analyzed was 300 with male to female ratio of 61:39. The mean age was 59 years. The most frequent site was tongue (42 %) followed by buccal mucosa (30 %). Distribution according to stage included T1 (14 %), T2 (24 %), T3 (14 %), T4 (47 %). The mean d3pth of invasion was 1.3 cm. pathological node positivity was found in 98 (33 %) patients. The mean follow up duration was 24 months. the overall survival at 24 months was 80 %. The depth of invasion more than 1.3 was found to have a significant increase in loco regional failure (p < 0.001). Conclusion: the depth of invasion is found to have an impact on loco regional control and overall survival for patients with oral carcinoma.

ER 024

CLINICAL UTILITY OF COX-2 MARKER AS A TOOL TO DECIDE TREATMENT STRATEGY IN CARCINOMA LARYNX

Elizabeth M Iype¹, Balakrishnan Rajan¹, Rajesh Singh¹ (rajeshsurg@gmail.com; 9847276427), Lakshmi G², Jassi², Department of Surgical Oncology¹ and Statistics and Research², Regional Cancer Centre, Trivandrum, India

Introduction: Squamous cell carcinoma (SCC) of the larynx is widely prevalent in India and is one of the leading cancer in males. In this study attempt is made to determine the relationship between clinicopathological characteristics and treatment outcome related to COX-2 expression. Objectives: To study the expression of COX-2 in SCC larynx and to determine its relationship with clinicopathological characteristics and to assess whether marker expression correlates with treatment outcome and prognosis. Methodology: Seventy two patients with stage III and IV of carcinoma of larynx underwent primary surgery from Jan 2006 to Dec 2010. Tumor expression of COX 2 was done by immunohistochemistry. Data were analyzed using STATA IC/11.2 software package and Chi square test. Results: Thirty seven patients (51.2 %) had node positivity, ipsilateral in 35 (48.6 %) and contralateral in 8 (11.1 %). Perineural spread was present in 19 (26.39 %) and extra capsular spread in 13 (18.06 %) patients. COX-2 was expressed in 35/37 node positive cases compared to 2/35 of node negative cases (p = 0.0001). Of the 59 patients with extra capsular invasion, 45 (76 %) showed COX-2 expression. Tumors with perineural invasion had more intense expression (7/19) than those without (11/53) (p = 0.011). Of the 21 patients who relapsed after treatment, 5 each showed mild, moderate and intense expression of COX-2. The actuarial disease free survival (DFS) of patients with nil to mild COX-2 expression was projected to be 58.5 % at 5 years and with moderate to intense was 55.1 %; the overall survival (OS) was 82.9 and 64.7 % for mild and intense expression respectively. Conclusion: Presence of intense COX 2 expression suggests nodal involvement; preoperative analysis may be useful to assess the need for neck dissection in SCC larynx even when clinically or radiologically neck nodes are absent. The intense expression of COX-2 in cases with perineural invasion warrants aggressive adjuvant treatment.

ER 025

SURGICAL MANAGEMENT OF POST RADIATION OSTEONECROSIS IN HEAD AND NECK CANCER

Elizabeth Mathew Iype¹, Rajesh Singh¹ (rajeshsurg@gmail.com; 9847276427),

Rejnish Kumar K², Ramdas k², Paul Sebastian¹ Departments of Surgical Oncology¹ and Radiation Oncology², Regional Cancer Centre, Trivandrum, Kerala, India.

Aim: 1. To evaluate the various surgical reconstructive options in post radiation osteoradionecrosis (ORN) in head & neck cancer patients. 2. To study the long term outcome of surgical management of these patients. 3. To study the frequency of surgery for post radiation sequelae in head and neck cancer among the total head and neck cancer surgeries. Methods: Retrospective analysis of all Head & Neck cancer patients with post radiation sequelae who underwent surgery in the department of Surgical Oncology, at Regional Cancer Centre, Trivandrum, India. Study period: Jan 2000-June 2014. Results: Twenty four patients underwent surgery for ORN constituting 0.3 % of total head & neck surgeries for that period. Twenty three received 52.5 Gy and one patient 60 Gyradiation. ORN was detected at a mean of 3 years following RT. Conservative management failed after an average of 13 months. Reconstruction was done with Pectoralis major myocutaneous flap and primary closure in one. Neck was addressed in seven patients. Histopathology was inflammatory for all except one where nodes were positive who recurred after 3 months. Median disease free interval was 39 months after surgery. Four developed locoregional recurrence, one developed second primary tumor and one death was reported. Conclusion: ORN is a rare complication but a major cause of morbidity following Radiotherapy for Head and neck malignancies. These patients usually do not have a residual disease and will have a good prognosis after surgery. So an extensive resection with wide margin is not required. Conventionally, Pectoralis major flap has been the cornerstone of reconstruction.

ER 026

Salvage Surgery for Oral cancer. Predictors and patterns of Early Recurrence

G. Lakshmi narayana MDS, FHNSO; C.S. Mani MS, Mch, FRCS.

Head and Neck Oncology unit; Madras Cancer Care Foundation, Chennai.

Objective: To evaluate role of known pathological prognostic markers in predicting early recurrence. To understand the patterns of early recurrence and its salvageability Study Design: Retrospective Single institution tertiary cancer centre with planned data collection. Methods: All patients included in the present study had undergone salvage surgery with curative intent for oral cavity Squamous cell carcinoma between 2008 and 2013. Patients with non-Squamous cell pathology and patients undergoing surgery for palliative intent were excluded. Data to identify the predictive value of prognostic factors and recurrence pattern were extracted. Results: 32 patients were included in the study. Over 19 (59 %) patients had tongue as a primary. Seventeen (53 %) patients presented with stage IV recurrence. The time to recurrence ranged from 3 to 36 months. Median follow up was 14 months. Thirteen patients (40 %) recurred after salvage surgery. All within 12 months. Three out of these thirteen were salvageable. Recurrence pattern showed 3 local, 6 regional, 3 loco-regional recurrences and 1 patient with distant metastasis. When pathological prognostic factors were compared in patients who had a recurrence, 61 % (n = 8) were in stage IVa, 53.8 % (n = 7) had Perineural Invasion and 69 % (n = 9) were node positive. Number of positive nodes and Extracapsular spread were equally distributed. Conclusion: Available prognostic markers did not predict for early recurrence in salvage setting. Stage IV disease, Perineural Invasion may be a potential factor to be looked in greater detail. Careful clinical selection with or without PET scan seems to be method of choice.

ER 027

Review analysis of Primary Tracheo-oesophageal puncture for Voice rehabilitation in laryngectomy patients

Suhaildeen K, Department of Surgical oncology, Cancer Institute (WIA), No. 18, Sardar Patel road, Guindy, Chennai - 600 036

Background: Voice restoration following total laryngectomy is an important part of patients’ rehabilitation and long-term quality of life. Tracheo-oesophageal puncture [TEP] is a procedure of choice in patients undergoing total laryngectomy which may be done primarily or secondarily. Here we retrospectively analyze the patients who underwent primary TEP following laryngectomy. Methods: Sixty patients who underwent total laryngectomy and tracheoesophageal puncture (TEP) with placement of Provoxvoice prosthesis between Nov 2009 and Dec 2013 were analyzed. TEP related parameters like percentage of patients speaking, and TEP related complications like, leakage through & around TEP and TEP displacement were recorded. TEP life span and reinsertion rate were calculated. These parameters were correlated with site of disease, extent of resection, type of closure, radiotherapy and pharyngo-cutaneous fistula. Results: From Nov 2009 till Dec 201360 patients underwent total laryngectomy with primary TEP insertions. Fifty-six [93.3 %] underwent primary surgery and 4[6.6 %] had salvage surgery. Fifty-six had laryngeal cancers and 4 had hypopharyngeal cancers. Total laryngectomy was performed in 43 patients, Total laryngectomy with partial pharyngectomy was done in 17 patients. Concomitant neck dissection was done in 26 cases, 44 patient received adjuvant radiation and 6 received chemoradiation. Ten (16.6 %) patients recurred locoregionally, and 2 (3.3 %) had distant metastasis. Fifteen patients had postoperative leak of which 14 settled with conservative approach and one required surgical closure with PMMC flap cover. Late complications occurred in 18 patients including minimal peri TEP leak in 9 patients, 4 underwent silastic wafer placement, prosthesis displacement occurred in 5, and granulation tissue formation in 3. One patient had aspiration of prosthesis. Two underwent TEP reinsertion. Median TEP life span was 16 months with maximum of 42 months. Forty patients had good quality voice at end of 1 year Conclusions: Primary TEP for patients requiring total laryngectomy is recommended since a second operative procedure can be avoided and speech obtained rapidly. A good success rate and a prolonged TEP life span makes this procedure feasible and cost effective with an acceptable complication rate. Keywords: Laryngectomy, Tracheooesophagealpuncture[TEP], Voice rehabilitation

ER 028

PECTORALIS MAJOR MYOCUTANEOUS FLAP RECONSTRUCTION AFTER MAJOR HEAD AND NECK RESECTIONS IN SALVAGE SURGERIES

Dr. Mohammed Ibrahim, Consultant Surgical Oncologist, Kauvery – HCG Cancer Centre, Chennai, India (+91 98841 72943) mdibrahimdr@yahoo.co.in

Introduction: Recurrences post primary chemo radiations are the most difficult group to be treated by Head and Neck oncologists. After the exploitation of chemotherapy and Radiation, surgery comes to the rescue. But during this salvage surgeries major resections have to be contemplated which require large volume reconstructive procedures. Pectoralis Major Myocutaneous flap Reconstruction is an ideal flap in this scenario. Aim of the study (purpose): To assess the usefulness of Pectoralis Major Myocutaneous flap in the reconstruction after major Head and neck resections during salvage surgery. QOL, Oncological safety and cosmetic outcomes after PMMC reconstruction. Materials and Methods: 136 patients, Period of study - 48 months, Recurrences in Head and neck cancers after primary chemo radiatiuon, Underwent major head and neck resections followed by immediate reconstruction with Pectoralis Major Myocutaneous flap, Oncological safety – margin status, Cosmetic outcome – photographs (1, 3, 6 month & 1 year), Questionnaire to evaluate her personal experience and QOL

Results:

• The age range was 31 to 72 years

• Operating time - 130 to 210 min (mean 153.9)

• Blood loss - 75 to 300 ml (mean 134.2)

• Skin island used for volume replacement - 4 × 3 cm to 10 × 6 cm

• Margin positivity or close margins – nil

• Complications:

  • Major wound complications - 3
  • Minor wound complications – 5
  • Fistula - 5
  • Flap loss - 5

• Follow up – 12 to 23 months

• QOL – Satisfactory score – 86 %

Conclusion: Head and Neck resection during salvage surgeries for local recurrences after Primary Chemo Radiation are a challenge to the treating Head and neck surgical Oncologists. PMMC is an ideal flap in such circumstances with good cosmetic outcome, oncological safety and QOL. Discussion: PMMC is an ideal versatile flap for Head and Neck Surgeons. Its usefulness can be extended to major head and neck resections in salvage surgeries which form the major challenge group for the onco surgeons.

ER 029

Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction

¹Dr. Rojakiran e-mail: rojakirangajula@gmail.com, Manikumari & M. Srinivasulu: MNJ Institute of Oncology and Regional Cancer Centre, Redhills, Hyderabad-500004

Objective: This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction post-mastectomy and post- breast conservation surgery.. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. Methods: A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap. Results: There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed. At our institution, we have employed latissimus dorsi myocutaneous flap for immediate reconstruction for patients who underwent mastectomy or breast conservation surgery. Our data and others more recently published demonstrate very acceptable aesthetic outcomes. Conclusion: The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.

ER 030

Should level III nodal clearance be done in patients undergoing axillary dissection for breast cancer? A Prospective Study

Dr. Bharath V.M. ¹, Dr. Madhu Muralee², Dr. Iqbal Ahamed M³

¹bharathveerabadhran@gmail.com, madhumuralee@gmail.com, Iqbal.m.ahamed@gmail.com Cell: 9895600534

Introduction Axillary nodal status is an important prognostic factor in carcinoma of the breast. The extent of axillary dissection that needs to be done continues to be a matter of debate due to the morbidity associated with the procedure and the controversy surrounding its therapeutic value. We looked into the incidence of level III lymph nodal involvement in carcinoma of the breast and the predictive factors. Materials and Methods 200 consecutive patients with Carcinoma breast operated in our institute. During axillary dissection levels I and II nodes were dissected out initially, followed by level III dissection. Univariate and multivariate analysis were done to look into the predictive factors. Results Median number of nodes retrieved in the axillary dissection specimen was 16 (range of 8–39) and the median number of nodes retrieved in level I + II and III were 13(range 5–36) and 2(0–10) respectively. One hundred six patients (55 %) had node negative disease. Of the 92 node positive patients 47 had disease confined to level I and II where as 45 had disease at all levels. Our study shows that in 49 % of node positive patients, level III nodes are involved and if undissected this macroscopic disease would be left behind. Four patients (2 %) had isolated nodal disease at level III (skip metastasis). Conclusion In patients with T3/T4 tumours, tumours located in upper outer quadrant and in patients with low axillary nodal involvement a complete axillary dissection including Level III dissection is mandatory.

ER 031

Feasibility and efficacy of reverse axillary mapping in identifying arm lymphatics in axilla in patients with early stage breast cancer.

Dr Balasubramanian venkitaraman ¹, Prof Sridevi ², Dr Sivram ganesamoni balapsgimsr@gmail.com,

Aim: To evaluate the feasibility and efficacy of reverse axillary mapping(RAM) using blue dye in identifying arm lymphatics in the axilla in patients with early stage breast carcinoma and to evaluate the degree of pathological involvement of arm lymphatics by breast carcinoma. Methods: Prospective study with enrolment of patients with early stage breast cancer (T1,T2,N0,N1), consenting to be a part of the study, being evaluated and treated at the breast oncology department, at cancer institute (WIA), Chennai. All subjects were subjected to injection of methylene blue (intradermal and subcutaneous, total 1 ml), injected into the medial aspect of arm, under anaesthesia, lymphatics and lymphnodes taking up blue dye identified in the axilla, dissected out during axillary nodal dissection and sent separately for pathological assessment. Results. Eighteen patients with early stage breast cancer, underwent RAM, blue lymphatics were identified in 14/18 patients, blue lymphnodes were identified in 12/18 patients. Mean lymph node yield from axillary dissection was 17.94 (11–32 nodes) and blue lymph node yield was 1.75 nodes. Nodal staging postoperatively was N0 in 13 patients, N1 in 2 patients and N3 in three patients (possible N3 axillary was suspected in all the three cases intraoperatively). Pathological involvement of the axillary lymphatics was seen in only one patient (patient with N3 axilla). In all the other 11 patients in whom axillary lymphatics could be identified, were found to be free of metastatic disease. Conclusion. Because of the low possibility of metastatic spread of carcinoma breast to arm lymphatics in early stage breast cancer patients, identifying arm lymphatics by RAM could enable in preservation lymphatic drainage of arm and thus possibly decrease the incidence of upper limb lymphedema in breast cancer patients.

ER 032

MALE BREAST CANCER: A SINGLE INSTITUTIONAL EXPERIENCE FROM INDIA.

Dr Dharma Ram¹, Dr. Veda Padama Priya Selvakumar², Dr. Ashish goel³, Dr. Kapil Kumar⁴, Department of Surgical Oncology, Rajeev Gandhi Cancer Institute and Research Centre, Sector-5 Rohini, New Delhi., Ph. 9958654196, dharmapoonia@gmail.com

Aim: To analyze the incidence and clinicopathological profile of male breast cancer in the Indian scenario. Materials & Methods: We retrospectively reviewed the records of all male patients with breast cancer who underwent surgery in the breast unit at our institute from January 2009 to May 2014. The demographic profile, the clinical and pathological parameters, the treatment patterns and outcome were analyzed. Results: Of the twenty four men equal number of patients had disease on either side. The mean age at presentation was 61 years [Range 42–77 years]. Most common presentation was breast lump [21/24]. The mean size of the lump was 3.4 cm in greatest dimension with a range of 1 to 7 cm in greatest dimension. Twenty-one men underwent MRM while three underwent simple mastectomy. Three were stage 0 & one of them stage I, 13 were stage II, 6 were stage III and 1 were stage IV. Twenty-one men had invasive ductal carcinoma while two had ductal carcinoma in situ and another had invasive lobular carcinoma. Fourteen patients had pN0 disease, 8 had pN1 disease and the rest had pN3 disease. Nineteen were estrogen receptor positive with 16 positive for progesterone receptor. One patient was positive for Her 2 neu and none were triple negative. Twenty underwent adjuvant chemotherapy, six underwent adjuvant radiation and 19 patients were given adjuvant Tamoxifen. One was lost to follow up, one developed local recurrence and another developed bone metastasis. Twenty one were disease free and alive at a median follow up of 13.6 months. Conclusion: In the present study majority of the men presented with early breast cancer in contrast to the other studies from india perhaps owing to increasing awareness in the national capital region. It is noteworthy that none of them were triple negative.

ER033

Sentinel lymph node biopsy for early breast cancer using methylene blue dye in India: The way forward!

Dr Shubha Garg¹, Dr Veda Padama Priya², Dr Ashish Goel³, Dr Kapil Kumar⁴,: Clinical Assitant, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre. Sector -5, Rohini, New Delhi-85, 0-9810650751, shubha_mbbs99@yahoo.com

Background: With the increasing incidence of early breast cancer in India it is imperative that sentinel lymph node biopsy (SLNB) replaces axillary clearance as the standard of care in clinically node negative axilla. In this background we evaluated the accuracy and validity of SLNB for early breast cancer using methylene blue dye. Materials & Methods: 38 female breast cancer patients with clinically node negative axilla underwent SLNB using methylene blue dye as a part of validation study from April 2013 to March 2014. Three milliliters methylene blue dye (10 %) was injected in subareolar location 15 min prior to surgery at 6’O clock position. Blue stained nodes were identified and sent for frozen section and final histopathological examination. All patients underwent complete axillary dissection subsequently. The presence and absence of metastases in sentinel nodes and axillary nodes were compared. Statistical analysis was carried out with 2 × 2 Contingency Table to know sensitivity, specificity, accuracy and positive predictive value. Results: The mean age of presentation was 51 years. Blue node was identified in 36/38 patients [94.7 %]. Mean tumor size was 4 cm. Of the 33 patients with IDC, 4 patients were T1 while 25 were T2 and 4 patients were post lumpectomy. DCIS was seen in rest of the 5 cases. Nineteen patients were ER/PR negative and 21 were negative for HER 2neu. The sensitivity, specificity, positive predictive value of SLNB in predicting axillary node status were 88.8, 100 and 100 % respectively and negative predictive value of SLNB 96.5 % with false negative rate of 11.1 % and overall accuracy of 97.2 %. Conclusions: SLNB using methylene blue is safe, feasible, accurate and applicable for early breast cancer in the Indian scenario. However it should be validated in large randomized trials before it is established as the standard of care in clinically node negative axilla.

ER 034

CENTRAL PEDICLED RECTUS ABDOMINIS MYOCUTANEOUS (CRAM) FLAP FOR BREAST RECONSTRUCTION: AN ALTERNATIVE FOR INDIAN WOMEN?

Choraria A¹, Bhutia TD¹, Agarwal N¹, Agarwal S¹, Ghosh MM², Ahmed R¹

¹Department of Breast Oncosurgery, Tata Medical Centre, Kolkata, India

²Department of Plastic Surgery, Columbia Asia Hospital, Kolkata, India

Aims: To study retrospectively the outcome of 22 patients who underwent CRAM flap reconstruction and to describe the surgical technique Material and Methods: Electronic medical records of 22 patients treated over 2 years were analyzed. The CRAM flap is a modification of the VRAM (Vertical Rectus Abdominis Myocutaneous) flap. It is based on the rectus abdominis muscle contralateral to the side of the tumour. The flap extends to include ipsilateral and contralateral skin from zones 1 and 2, including both the supra and infra umbilical areas. A central 2 cm strip of anterior rectus sheath overlying the rectus abdominis is maintained, through which the vascular perforators pass to supply the overlying skin. The flap is rotated on the superior epigastric pedicle, and is tunneled into position. The rectus sheath is closed anatomically. Results: The average age was 39 years (23–57 years). Ten were right sided and 12 left sided. Twenty-one patients had infiltrating duct carcinoma and 1 benign phylloides tumor. Nineteen patients underwent surgery following 6 cycles of neoadjuvant chemotherapy while 3 cases were upfront reconstruction. Seventeen patients received post-operative radiotherapy. Three cases had partial flap necrosis which required debridement and split thickness skin grafting, 1 patient had umbilical wound gaping and 8 patients had minor complications (wound infection managed with dressing and antibiotics). There was no total flap loss or mortality in our study. The average follow up period was 6 months (1–16 months). Conclusions: Pedicled CRAM flap is straight forward for surgeons familiar with midline or paramedian laparotomy. The midline defect is easily closed, abdominoplasty is not required. The flap is safe after chemotherapy, stands well to radiotherapy, and with skin sparing techniques gives good cosmetic results. Easy donor site dissection, secure superior pedicle, simple flap positioning by tunneling and cosmetically acceptable central vertical donor scar are favorable points.

ER 034

Axillary lymph node ratio versus nodal stage as a predictor of breast cancer survival.

D. Yadav*, G. Gopal*, M. Kumar*, K. Thakar*, A. Joshipura*, R. Patel*, P. Kshirsagar*, S.J. Pandya^##. Deptt. Of Surgical Oncology, GCRI, Ahmadabad Gujarat Email: drkumardinesh@yahoo.co.in

Background: Compared to conventional pathological axillary nodal staging (pN), the LNR (i.e. the ratio of positive over excised lymph nodes) offers potentially improved prognostication, selection of adjuvant therapy and inter-institutional comparability. Cut-offs of 0.20 and 0.65 were proposed to classify patients into low, intermediate and high risk groups. We perform an independent external validation of the LNR concept. Material & Methods: 225 patients undergoing primary surgery for breast cancer at tertiary care centre in Gujarat, were retrospectively analyzed using Cox multivariate regression. Median follow up was 42 months. Results: Using the above cut-off points, 10 year DFS rate of 74, 57 and 48 % and adjusted hazard ratio of 1.19, 2.21 and 6.88 were obtained for the low, intermediate and high risk groups respectively. The corresponding risks for the pN1, pN2 and pN3 categories were 1.74, 1.74 & 1.35 representating inadequate, even reversed prognostic stratification. On including both LNR and pN as continuous variables, the LNR continued to remain prognostically significant with an adjusted HR of 12.33 in contrast to the node number. Conclusions: The LNR outperformed the pN staging in predicting DFS in our cohort of patients, irrespective of whether it was modeled as a categorical or continuous variable. Simultaneous inclusion with pN only increased its prognostic weight and resulted in exclusion of pN from the multivariate model. Our study thus provides independent external validation of the LNR concept and contributes to the growing body of literature supporting the incorporation of a ratio-based system into breast cancer staging.

ER 035

Five year retrospective analysis of triple negative breast cancer in a tertiary care cancer centre.

G. Gopal*, D. Yadav*, K Thakar*, M. Kumar*, A. Joshipura*, R. Patel*, P. Kshirsagar*, S.J. Pandya^##. Deptt. Of Surgical Oncology, GCRI) Ahmedabad, Gujarat. Email-drgirdhargopl96@gmail.com

Aim of study: Female breast cancer is about 10 % of total cancer in our institute. This analysis was done to see triple negative among these patient with their survival strength up to 5 years in different age group, Stage and chemotherapy protocols. Material and methods: 200 IHC proven TNBC patients registered and treated till 2012 were retrospectively selected for the study. Overall survival up to 5 years was observed on the basis of stage and different age groups and chemotherapy regimen. All patients had surgery, conventional EBRT and adjuvant chemotherapy. The survival analysis was performed using the Kaplan-Meier method. Results: Majority of patients (41 %) were in age group 21–30 years. Stage IV was seen in 18 % of patients at diagnosis and mainly in 21–40 years age group. Only 3 % females were >70 years and were of stage I and II. Overall 5 year survival in stage I in CAF/CEF group was 37.5 % as compared to TE group 93 % (p < 0.0001). About 41 % were in younger age group. At time of diagnosis 18 % of patients were of stage IV of which mainly in 21–30 years age. Conclusion: Triple negative in GCRI is about 11.8 %. We observed it mainly in younger patients with highly aggressive behaviors. Taxane based chemotherapy gives better result as compared to anthracycline based regimens (p < 0.0001). However ours being a retrospective analysis, we feel that a prospective randomized control study can be carried in Indian scenario.

ER 036

Metaplastic carcinoma of breast: Case series and review of literature.

Dr. Vivekanand Sharma, Dr. Abhinav Pandey, Dr. Raj Govind Sharma

Surgical Oncology Division, Upgraded Department of Surgery, S.M.S. Medical College and Hospital, Jaipur

Aim: To study clinico-pathology of Metaplastic carcinoma of the breast Methods: Data of five patients diagnosed with metaplastic carcinoma either on fine needle aspiration cytology or final histopathology report were reviewed and patients were followed prospectively. Results: The median age was 40 years (range 38/60). The median tumor size was 5 cm. (range 4/8 cm.). Two cases (40 %) were identified carcinosarcoma and 2 (40 %) as squamous cell carcinoma of ductal origin and one (20 %) as spindle cell carcinoma. Only estrogen receptors were positive and that too in one patient. Modified radical mastectomy was performed in four patients and one underwent lumpectomy followed by axillary node dissection. Axillary lymph node metastasis were present in 2 patients. Adjuvant chemotherapy was given to all patients and postoperative radiotherapy to one. Two patients relapsed with median time of relapse of 12 months. Conclusion: Metaplastic carcinoma of breast is a rare and aggressive form of breast malignancy, with high rates of local recurrence. The disease tends to be estrogen/progesterone receptor negative and Her2neu negative. TNM stage, tumor size and axillary lymph node status are significant prognostic indicators of survival. Due to lack of data there is limited knowledge about this rare form of tumor, hence large collaborative studies are indicated.

ER 037

Secretory carcinoma of the breast: A case report and review of literature

Dr. Vivekanand Sharma, ²Dr. Suresh Singh, ³Dr. Raj Govind Sharma

Surgical Oncology Division, Upgraded Department of Surgery, S.M.S. Medical College and Hospital, Jaipur

Aim: To study clinicopathologic features, treatment and outcome in case of secretory carcinoma of breast. Methods: We present a case report of a 55 year old lady with no family history of breast cancer who presented with 1 month history of a lump in the right breast. The patient was post-lumpectomy referred to us with the histopathology suggestive of secretory carcinoma. On Clinicoradiological evaluation there was no evidence of metastatic disease. Based on initial biopsy report patient underwent a mastectomy with axillary lymph node dissection Results: The biopsy of the lumpectomy specimen showed a 3 × 2 cm mass harboring microscopically an intraductal neoplasm with the tumor cells showing glands and microcystic spaces showing abundant pale secretions. The cells had abundant pale staining cytoplasm with small round low grade nuclei. There was no perineural or vascular invasion. The biopsy hence suggested secretory carcinoma. Immunohistochemistry of the tumor on review of paraffin embedded blocks showed neoplastic cells with a triple negative result (estrogen-receptor and progesterone-receptor and Her-2/neu protein expression negative). The tumor also stained positive for vimentin, periodic acid Schiff (PAS) and S100. The patient received adjuvant chemotherapy. Periodic follow-up examinations after the surgical procedure and chemotherapy have shown no evidence of recurrence and distant metastasis. Conclusion: Secretory breast cancer is a very rare tumor that is best treated surgically. Conservative surgery has little role in adults owing to high rate of local recurrence. The role of adjuvant therapy also remains poorly defined and better understanding may allow targeted therapies in the future.

ER 038

BILATERAL BREAST CANCER: UNCOMMON BUT UNIQUE ENTITY!

Dr Shubha Garg¹, Dr Veda Padama Priya², Dr Ashish Goel³, Dr Kapil Kumar⁴

¹Clinical Assitant, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre. Sector -5, Rohini, New Delhi-85, 0-9810650751, shubha_mbbs99@yahoo.com

Aim: To analyze the clinicopathological profile of patients with bilateral breast cancer at a tertiary care cancer institute in Northern india. Methods: We retrospectively reviewed the records of patients with breast cancer who underwent surgery at our institute from January 2012 to June 2014. The clinicopathological profile of patients with bilateral breast cancer were studied. Results: Of the 37 women with bilateral breast cancer, 23 were synchronous and 14 metachronous. For metachronous lesions the appearance of second primary ranged from 6 months to 13 years. Mean size of lump in either breast was 4 cm. In 9 cases the contralateral breast lesion was detected by surveillance imaging. Three cases were metastatic at presentation. Eight cases received neoadjuvant chemotherapy. Nineteen patients underwent bilateral mastectomy, 2 cases underwent bilateral BCS and in 2 cases unilateral mastectomy was done and rest of them had combination of breast conservation and mastectomy. In 27 cases, the histology was IDC in both sides while in 10 patients the histology was IDC on one side and DCIS on contralateral side. Bilateral axillary lymph node positivity was seen only in 2 cases. Pathological staging was same in 2 cases T2N1. In eight patients the histology was same on both sides including grade, ER/PR and HER 2 neu status favoring metastasis rather than second primary. All patients received adjuvant chemotherapy for either breast. Radiotherapy given to 12 ipsilateral breasts and in 8 cases both breasts received radiation. Twenty six cases received hormonal therapy. Four patients lost to follow up. Thirty-three patients are alive, 30 are disease free at a mean follow up of 15 months. Conclusions: Bilateral breast cancer poses unique and challenging issues with respect to early detection, surgical choices, tailoring adjuvant therapy and optimizing radiation. The management has to be individualized to optimize outcome.

ER039

BREAST CONSERVATION AFTER NEOADJUVANT CHEMOTHERAPY – OUR INITIAL EXPERIENCE

Dr Dharma Ram¹, Dr. Manish singhal², Dr. Juhi agrawal³, Dr Veda padama priya selvakumar⁴, Dr. Ashish goel⁵, Dr. Sandeep Mehta⁶, Dr Kapil Kumar⁷,

1 Department of surgical oncology, Rajiv Gandhi Cancer Institute & research centre, Sector 5, Rohini, New Delhi, Ph. 9958654196, dharmapoonia@gmail.com

Centre, Sector-5 Rohini, New Delhi, 9810065202, kdrkapil@yahoo.in

Aim: To analyze the feasibility and outcome of breast conservation after neoadjuvant chemotherapy in the Indian scenario. Methods: We retrospectively reviewed the records of all patients with breast cancer who underwent breast conservation surgery after neoadjuvant chemotherapy at our institute from January 2012 to may 2014. The demographic profile, clinicopathological parameters, treatment pattern and outcome were analyzed. Results: Seventeen patients underwent breast conservation after neoadjuvant chemotherapy. Mean age at presentation was 41 years (Range: 23–58 years). Fifteen patients presented with breast lump while 2 presented with axillary lump. Left: right - 11: 6. Stage distribution IIB: 4,IIIA: 8,IIIB: 5. The number of cycles of neoadjuvant chemotherapy varied between 3 (11/17)- 6(6/17). Three patients underwent wire localization of lesion for conservation. All patients underwent level III clearance. Mean node retrieval was 19.8. Oncoplastic surgery done in 8 patients, Mini Latissimus dorsi muscle flap in 6 patients and 3 underwent fascio cutaneous flap reconstruction. On pathological assessment, 6 patients showed significant response 2 with no residual disease. The margins of resection were free in all patients and close in one of the patients. Six patients were pN0,6: pN1,4: pN2 and 1: pN3. None had skin involvement on pathological evaluation. Five patients were triple negative, 9 hormone receptor positive and 5 her 2 neu positive. All patients received adjuvant radiation. Nine patients received adjuvant hormonal therapy. At median follow up of 14 months 14 patients are alive & disease free. One patient died of pulmonary metastasis and 2 lost to follow up. Conclusion: Breast conservation is safe and feasible after neoadjuvant chemotherapy. A close integrated multi disciplinary approach of surgeon, oncologist and plastic surgeon is mandatory to optimize outcome.

ER 040

ADENOLIPOMA OF THE BREAST: A CLINICORADIOLOGICAL ENTITY AND PATHOLOGIST’S DILEMMA!

Dr Dharma Ram¹, Dr. Veda Padama Priya Selvakumar², Dr. Ashish goel₃, Dr. Kapil Kumar⁴,

Department of Surgical Oncology, Rajeev Gandhi Cancer Institute and Research Centre, Sector-5 Rohini, New Delhi. Ph. 9958654196, dharmapoonia@gmail.com

Aim: We hereby report a case of giant adenolipoma of the breast in a young female. Case report A 29 year old lady presented with painless lump left breast of 4 years duration. Physical examination revealed a firm mobile lump 8 × 9 cm size which on MR mammogram showed a well circumscribed fatty mass with type 1 (persistent) kinetics “breast in a breast appearance”. Trucut biopsy showed stromal and adipose tissue hyperplasia only. She underwent lumpectomy. Final histopathology reported a well a well circumscribed lesion composed of mature adipose tissue, breast ducts and lobule surrounded by fibrocollagenous tissue favoring adenolipoma. Discussion Breast hamartomas are rare benign lesions that are composed of varying amounts of glandular, fibrous, adipose and smooth muscle tissue. The most characteristic histological feature of hamartomas is the presence of lobules within a fibrotic stroma. Breast hamartomas have become more frequently diagnosed due to the increased use of mammography, but they may be mistaken for neoplasms. Surgical removal is the curative method for breast hamartomas. If there is a coincidental epithelial malignancy in the lesion, there is a potential for recurrence. Conclusion: Adenolipoma are clinically and radiologically quiet characteristic disease but it deceive pathologist. Hence high index of suspicion needed to correctly diagnosis it. We report this case for its unique clinic radiological features.

ER 041

IMAGE GUIDED LOCALIZATION FOR NON-PALPABLE BREAST LESIONS: EMERGING TREND IN INDIA

Dr. Veda Padma Priya Selvakumar, Dr. Shubha Garg, Dr. Ashish Goel, Dr. Avinash Rao, Dr. A.K. Chaturvedi, Dr. Kapil Kumar, Dept of Surgical Oncology, RGCI&RC. Email: privedsri@gmail.com

Aim: To analyze the clinic-pathological characteristics of non-palpable breast lesions at a tertiary care cancer institute in India. Methods: We retrospectively reviewed the records of patients with non palpable breast lesions who underwent either stereotactic or MR guided wire localization at our institute between November 2010 and June 2014. The clinicoradiological profile, pathological correlates and management strategies were analyzed. Results: A total of 35 women with non palpable breast lesions underwent stereotactic or MR guided wire localization followed by excision for BIRADS IV/V lesions. In 19 patients, the lesions were detected on mammography and 12 were detected by MRI. Four patients underwent wire localization of the residual tumor post NACT. Preoperative FNAC was inconclusive or suspicious in all but 5 patients where it was positive. Thirty patients underwent wire localization by sterotactic /USG guidance while 5 patients underwent MRI guided localization. All patients underwent wide excision subsequently. 17/35 were malignant. Histopathological evaluation reported IDC in 6 patients, ILC in one patient, DCIS in 6 patients, ADH in one patient, lobular neoplasia in one patient and benign lesions in 16 patients. All four patients post NACT had residual tumor on final histopathology. Out of the 17 malignant cases, five women underwent mastectomy and 12 underwent breast conservation and adjuvant radiation. Six patients were stage 0, three stage I and four stage II. Eight patients received adjuvant chemotherapy. Twelve patients were positive for ER /PR and received adjuvant hormonal therapy. At an mean follow up of 10 months, all of them are alive and disease free. Conclusion: About one half of the non palpable breast lesions studied at our institute were malignant. However they present at an earlier stage, more suitable for conservation and have a good prognosis.

ER 042

Breast Conservation Surgery Conversion Rate Following Neoadjuvant Chemotherapy

Dr. Abinaya R C, Dr. RiteshTapkire, Dr. Ravikannan, Dr. Vinodh Kumar Adithyaa A.

Aim: Breast conservation surgery (BCS) is gaining popularity worldwide following the advent of neoadjuvant chemotherapy (NACT) for breast cancer patients. The aim of the study was to assess the BCS conversion rate following NACT in locally advanced breast cancer patients. Methodology: This is a retrospective study of 86 patients with locally advanced breast cancer who were treated in a comprehensive cancer center at North East India from 2009 to 2012. Patients with stage II and III breast carcinoma were included in the study. The diagnosis was confirmed by pretreatment core biopsy. Immunohistochemical stains for ER, PR and HER2/Neuwere obtained. Three to six cycles of either anthracyclin(5-FU,Adriamycin or epiribicin and cyclophosphamide) based regimen or taxane-anthracyclin(Docetaxel with Adriamycin and Cyclophosphamide or Epirubicin) based regimen was given to patients receiving NACT. Post treatment responses were assessed and all patients with tumor size of 5 cm or less were offered the option of Breast Conservation. Results: Eighty-six cases were operated for breast cancer from 2009 to 2012. Thirty-six (41.8 %) patients received NACT. Out of the 15 patients who underwent BCS,8 patients were eligible for upfront BCS. Seven patients (19.4 %) were converted to BCS instead of modified radical mastectomy following NACT. Conclusion: The primary goal of neoadjuvant chemotherapy in locally advanced breast cancer patients is to improve disease free survival and overall survival and to have a better idea of prognosis based on response to neoadjuvant treatment. Though breast conservation is not the primary goal of neoadjuvant chemotherapy, it can be considered as an additional advantage and should be considered as an option for every patient with breast cancer in stage II or III.

ER 043:

FACTORS INFLUENCING NON-SENTINEL NODE INVOLVEMENT IN SENTINEL NODE POSITIVE PATIENTS AND VALIDATION OF MSKCC NOMOGRAM IN INDIAN BREAST CANCER POPULATION

Dr. Naveen Padmanabhan, Dr. Selvi Radhakrishna, Dr. Ann Kurien, Dr. Sushma Patil, Apollo Speciality Hospitals, Chennai Email. drnaveenp.in@gmail.com

Aims: Current guidelines recommend completion axillary lymphnode dissection (ALND) when sentinel lymphnode (SLN) contains metastatic tumor deposit. In consequent ALND sentinel node is the only node involved by tumor in 40–76 % of cases. Recent studies demonstrate the oncologic safety of omitting completion ALND in low risk patients. Several nomograms(MSKCC, Stanford, MD Anderson score, Tenon score) had been developed in predicting the likelihood of additional nodes metastatic involvement. We evaluated accuracy of MSKCC nomogram and other clinicopathologic variables associated with additional lymph node metastasis in our study group. Methods: A total of 332 patients with primary breast cancer patients underwent SLN biopsy during the period Jan 2007 to June 2014. Clinicopathologic variables were prospectively collected. Completion ALND was done in 64 patients who had tumor deposit in SLN. The discriminatory accuracy of nomogram was analysed using Area under Receiver operating characteristic curve (ROC). SPSS version 17.0 was used for statistical analysis. Results: SLN was the only node involved with tumor in 69 % (44/64) of our patients. Additional lymph node metastasis was seen in 31 % (20/64). Eleven patients had only one additional lymph node metastasis, eight patients had 2–5 nodes and one had 6 additional lymph node metastasis. On univariate analysis, extracapsular infiltration in sentinel node and total number of nodes harvested in axillary dissection were significantly associated (p < 0.05) with additional lymph node metastasis in the axilla. Increasing ratio of no. of sentinel node positive and total SLN harvested showed a trend towards additional lymph node metastasis though not statistically significant. Area under ROC curve for nomogram was 0.58 suggesting poor predictability. Conclusions: The MSKCC nomogram could not reliably predict additional lymph node involvement in our study population. Extracapsular infiltration in sentinel node and total number of axillary nodes harvested, predicted the likelihood of metastasis in additional non sentinel nodes.

ER044

Decision making factors among early breast cancer patients in choosing breast-conservation surgery or modified radical mastectomy.

Gargi S Kumar^*, Vidhubala E, Sri Devi V

Department of Psycho-oncology, Department of Surgical Oncology, Cancer Institute (WIA)

Background: Modified Radical Mastectomy (MRM) or Breast Conservation Surgery (BCS) accompanied by radiation therapy produce equal outcome in terms of survival among Early Breast Cancer Patients (EBCP). However, majority of the women opt MRM though offered BCS due to various factors. The current study is to identify the decision making factors among EBCP in choosing BCS or MRM. Method: EBCP (n = 44) enrolled between January to June 2014 at the Cancer Institute, suitable to undergo BCS were interviewed once they chose the treatment. A semi structured interview was conducted using four key questions (the options given, understanding about the options, person who made the decision and the factors which helped them to decide MRM or BCS. After taking the consent, verbatim of interview were recorded and content was analyzed. Result: Age ranged from 29 to 78 years. All the 44 patients were offered both options and they reported that they understood the implications of both the options such as the procedure, additional treatment modality required (radiation therapy), duration of treatment and hospital stay, treatment outcome such as survival, body image, etc. Of the patients, 10 chose BCS and 34 chose MRM. The patients reported that the decision was made by themselves, family members and doctors. The factors which made them to choose MRM were fear of recurrence, additional treatment (radiation therapy), duration of treatment, logistics and family issues. The patients believed that MRM will have a better survival. This was due to the interaction with other patients underwent MRM and second opinion sought elsewhere. The reasons for choosing BCS were doctor’s advice, body image and self esteem. Conclusion: Despite the options and benefits explained by the doctors, the psychosocial factors and the previously treated patients found to play a role in making decision among EBCP. The patients and the family members need to be empowered to make the decision thereby making the breast conservation possible for suitable patients. Exploring further to understand the influential factors through a systematic study will help us to provide appropriate support to the patients to help in the decision making process.

ER045

THORACO – EPIGASTRIC FLAP – A NOVEL TECHNIQUE IN CHEST WALL RECONSTRUCTION FOR LOCALLY RECURRENT BREAST CANCER

Dr. Mohammed Ibrahim, Consultant Surgical Oncologist, Kauvery – HCG Cancer Centre, Chennai, India E mail. mdibrahimdr@yahoo.co.in

Introduction: Chest wall recurrence is one of the challenges in breast cancer survivors. Isolated chest wall recurrences usually occur after exploitation of all three modalities namely, Surgery, Chemotherapy and radiation to chest wall. Chest wall recurrences usually require one or two rib resections for oncological clearance. AIM: To assess the usefulness of Thoraco Epigastric flap in the reconstruction of chest wall for isolated chest wall local recurrence for carcinoma breast. Oncological safety and cosmetic outcomes after chest wall reconstruction Materials and Methods: 36 patients, Period of study - 24 months, Isolated chest wall involvement with or without rib infiltration, Undergo immediate chest wall reconstruction with mesh and thoraco epigastric flap, Oncological safety – margin status, Questionnaire to evaluate her personal experience after the reconstruction. Results: The age range was 31 to 65 years, Patients with positive or close margin MRMs – 16, Patients with margin negative MRMs – 20, Operating time -130 to 210 min (mean 153.9), Blood loss - 75 to 300 ml (mean 134.2), Size of Skin island used for volume replacement - 4 × 3 to 10 × 6 cm, Margin positivity or close margins – nil, Complications: Major wound complications – 3, Minor wound complications – 5, Seroma – 5, Follow up – 12 to 23 months. Conclusion: Isolated Chest Wall recurrences are completely resectable if we have an oncoplastic option like Thoraco Epigastric Flap. This has increased the oncological safety with less number of margin positive resections with immediate reconstruction of chest wall with good cosmetic outcome and less donor site morbidity.

ER 046

“LATTISIMUS DORSI FLAP ONCOPLASTY IN BREAST CONSERVATION SURGERY – COSMESIS AND ONCOLOGICAL SAFETY – A PROSPECTIVE STUDY”

Dr. Mohammed Ibrahim, Consultant Surgical Oncologist, Kauvery – HCG Cancer Centre, Chennai, India E mail. mdibrahimdr@yahoo.co.in

Introduction: Breast Conservation is the treatment of choice for Early Breast Cancer. There is a greater expansion in the scope of BCS with contraindications shrinking over the years. Oncoplasty has come as a great help for breast conservation with increased cosmesis but with no oncological compromise. Aim of the study (purpose): Oncological safety and cosmetic outcomes in breast conservation following large volume resections using oncoplastic techniques, The role of oncoplastic techniques in improving breast conservation rates in our clinical practice. MATERIALS AND METHODS: 50 patients, Period of study - 36 months, Large volume resections, Undergo immediate partial breast reconstruction with Lattisimusdorsi flap, ncological safety – margin status, Cosmetic outcome – photographs (1, 3, 6 & 1 year), Questionnaire to evaluate her personal experience after the reconstruction, Cosmetic Assessment (Subjective) - Lent–Soma Score. Results: The age range was 20 to 65 years, Primary BCS – 45, Post NACT BCS – 5, Operating time - 110 to 210 min (mean 153.9), Blood loss - 75 to 350 ml (mean 134.2),Volume of resection - 30 to 300 cm³, Skin island used for volume replacement - 4 × 3 to 14 × 6 cm, Margin positivity or close margins – nil, Complications:, Major wound complications – 3, Minor wound complications – 5, Seroma – 7, Lymphedema – 3, Follow up – 12 to 23 months, 46 patients had scores >/=3, 4 patients had score <3. Conclusion: Oncoplasty in breast conservation surgery has an increased cosmesis, both subjectively and objectively, with no compromise in the oncological safety. Lattisimusdorsi is an ideal flap for large volume reconstruction after breast conservation surgery with lesser donor site morbidity.

ER 047

Bilateral Breast cancers A retrospective study

Dr Shubha, Veda Padama Priya, Shuba Garg, Ashish Goe, Kapil Kumar

Garg, Clinical Assitant, Surgical Oncology –Breast and Thoracic Unit, Rajiv Gandhi Cancer Institute and Research Centre. Sector -5, Rohini, New Delhi E mail: privedsri@gmail.com, shubha_mbbs99@yahoo.com

Introduction: WE retrospectively have analyzed the data of 37 patients. Twenty three were synchronous bilateral breast carcinoma from year 2012 to 2014. Fourteen were metachronous bilateral breast and appearance of second primary ranged from 6 months to 13 years. Materials & Methods: Mean size of lump on clinical in either breast was 4 cm and in 9 cases contralateral breast lesion was detected by imaging. In only 3 cases at time of diagnosis metastasis was positive. Eight cases received neoadjuvant chemotherapy. Bilateral MRM was done in 19 cases. Both side IDC was seen in 27 cases. Only 5 cases showed same morphological grade on HPE. Only 2 case had bilateral axillary lymph node positive. Pathological staging was same in 2 cases T2N1. Nine cases had ER/PR positive for both side but percentage of positivity none showed value. No patient had HER 2nu positive on both side. All patients received adjuvant chemotherapy for either breast. Radiotherapy was given to 12 single breasts and in 8 cases both breast received radiation. Twenty six cases are on or will be started on hormonal therapy. Four patients are lost in follow up. Rest all patients are alive, free from disease and on regular follow up Conclusion: WE retrospectively have analyzed the data of 37 patients. Twenty were synchronous bilateral breast carcinoma from year 2012 to 2014. Fourteen were metachronous bilateral breast and appearance of second primary ranged from 6 months to 13 years.

ER 048:

PROSPECTIVE STUDY OF HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY (HIPEC) IN PERITONEAL CARCINOMATOSIS - SHORT TERM RESULTS

Dr. Prasanna G, Dr. Somashekhar SP, Dr. Shabber S Zaveri, Dr. Rajshekhar Jaka, Dr. Monika Pansari, Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore

Aim: To analyze the outcomes of cytoreductive surgery and HIPEC in patients with peritoneal carcinomatosis from various cancers. Methods: Twenty three patients with peritoneal carcinomatosis from 15 recurrent/advanced ovarian cancers, 4 recurrent colorectal, 1 limited peritoneal metastasis from gastric carcinoma, 1 pseudomyxoma, 1 primary peritoneal carcinoma, 1 recurrent fallopian carcinoma were previously treated by surgery and systemic chemotherapy then submitted to surgical cytoreduction and HIPEC. HIPEC was done using FDA approved Belmont® with either closed/open/bidirectional technique at 41.5 °C (41–43 °C) for 30–90 min. The median follow-up period-10 months (range: 2–15). Results: Among twenty three patients 18 were females and 5 were males. Mean age was 52.09 years (25–78). Average duration of surgery was 9.58 h (6–19) with blood loss in average 1275+/−1100 ml. Average hospital stay was 15.96 days (10–42). GI recovery happened in mean 5.7 days (4–10). As per protocol all patients observed in ICU for first 2 post-op days. Five patients needed extended stay in ICU for either ventilatory support (2 cases) or correcting severe electrolyte disturbance (3 cases). Major morbidity occurred in 4 (17 %) patients requiring reoperation. No 60 days mortality was observed. One patient died at 5th month due to pulmonary embolism, another in 6th month due to sepsis in the follow up period. Conclusion: The results of our study indicate the feasibility and the potential benefit of a protocol including systemic chemotherapy, surgical cytoreduction and HIPEC in patients with peritoneal carcinomatosis with no mortality and acceptable morbidity. A phase III trial to compare this approach with conventional treatment is needed.

ER 049

MARJOLIN’S ULCER: CLINICOPATHOLOGICAL STUDY OF 94 CASES AND REVIEW OF LITERATURE

Dr Sanjay Kumar Yadav¹, Prof N K Jha², Dr D K Sinha³, Dr Mini Sinha⁴, Dr Jitin Yadav¹, Dr Anjana Gandhi¹, Dr Abhinav Anand¹, Dr K Adithya Reddy⁵ EMAIL- sky1508@gmail.com Deptt. of General Surgery, Rims, Ranchi, Jharkhand(India)- 834009

Aim: Marjolin’s ulcer is a rare and aggressive skin malignancy, which arises in a setting of chronic skin wounds or scars. This study was conducted to describe the clinicopathological presentation and treatment outcome of this condition in our local setting and to identify predictors of outcome. Methods: This is a retrospective study of histologically confirmed cases of Marjolin’s ulcer seen at Rajendra Institute Of Medical Sciences, Ranchi, over a period of 3 years between March 2011 and February 2014. Data were retrieved from patients’ files and analyzed using SPSS computer software version 16.0 Results: A total of 94 cases were studied. Male to female ratio was 1.76:1. Most common causative factor was flame burn scar (91.5 %). The mean latent period between original injury and diagnosis of Marjolin’s ulcer was 12.04 ± 4.25 years. Only 4.3 % of the reported cases were grafted at the time of injury. Most common site was lower limb (55.3 %) followed by upper limb(26.6 %). The vast majority of patients (74.5 %) presented with large tumors of ≥ 5 cm in diameter. Lymph node metastasis at the time of diagnosis was recorded in 5.3 % of cases and distant metastasis was not present in any case. Squamous cell carcinoma (98.9 %) was the most common histopathological type. Wide local excision was the most common surgical procedure performed in 96.8 % of cases. Surgical site infection was the most common complication in 26.6 % of patients. Local recurrence was noted in 19.1 % of cases who were treated surgically. Mortality rate was 8.5 %. Conclusion: Marjolin’s ulcers are not rare in our setting and commonly occur in flame burn scars that were not skin grafted and were left to heal secondarily. A high index of suspicion is required in the management of chronic non-healing ulcers and all suspected lesions should be biopsied.

ER 50:

ANATOMICAL ANOMALIES IN SURGICAL ONCOLOGY PRACTICE

Prof. Rajaraman R, Subbiah Shanmugam, Subbiah, Navin

Centre for Oncology, Government Royapettah Hospital, Chennai.

Aim: Congenital anomalies in surgical practice range from life threatening defects that require surgical correction to minor abnormalities that can cause diagnostic dilemmas or increased surgical morbidity by altering anatomy. We present a retrospective case series of Anatomical anomalies from a tertiary care surgical oncology center with specific reference to cancer association, diagnostic pitfalls, and surgical hazards posed by these anomalies. Methods: A total of 12,538 patients attending surgical oncology department with a diagnosis of malignancy were screened for congenital anomalies. Those with obvious congenital disorders and others with anatomical variations documented at surgery were included in the study. All patients were subjected to stage appropriate standard work up as required for the primary cancer diagnosed. Association with cancer, diagnostic dilemmas created, influence on treatment decisions, and their impact at surgery were studied. Results: Overall 21 anomalies were noted, giving a prevalence rate of 0.16 %. The genitourinary system was the most affected (38 %) with Pelvic kidney and ureteric duplication predominantly encountered. In 11 patients the defect was recognized at surgery, a preoperative suspicion based on imaging was possible only in 4 cases (pelvic kidney and situs inversus). The defects required alteration in treatment plans, additional surgical procedures and an awareness to reduce morbidity. Conclusion: Anatomical Anomalies are rare, a majority are recognized at surgery, an awareness and early identification can prevent surgical morbidity. A pretreatment diagnosis is possible for some based on clinical and imaging information. Most anomalies do not result in adverse oncological outcome.

ER 051:

Cutaneous Malignant Melanoma: A 10 year experience from a tertiary cancer centre in south India

Prof. Rajaraman R, Subbiah Shanmugam, Subbiah, Navin

Centre for Oncology, Government Royapettah Hospital, Chennai.

Introduction: Incidence of cutaneous melanoma is much lower in tropical countries (0.7–1.1 %) than in the west (4 %) and therefore remains understudied. The aim of the present study was to analyse the incidence, clinical characteristics, pathology and prognosis of cutaneous melanoma presenting over 10 year period in a tertiary cancer centre. Materials and Methods: Retrospective analysis of case records of patients with cutaneous malignant melanoma who presented to hospital between 2004 and 2013 was done. Results: 50 patients were evaluated. The mean age of was 47 years. There were 25 males and 25 females and the median follow up period was 40 months. Ulcerated pigmented lesion was the most common presenting symptom, 38/50(76 %) in our patients. Acral regions were the most common site of clinical presentation 36/50(72 %). Stage wise distribution was as follows StageI: 8 %, StageII: 70 %, stageIII: 6 %, stageIV: 16 %. Forty two patients were operated. Wide local excision(WLE) with split skin grafting was done for 22 patients and WLE alone for 11 patients. Amputation was done for 4 patients (1 Lisfranc, 1 forefoot, 1 transmetatarsal, 1 hindquarter). WLE with local flap reconstruction was done for 3 patients Palatoalveolar resection was done 1 patient and for 1 patient bilateral inferior maxillectomy was done. Four patients were treated with chemotherapy, 1 patient was treated with radiotherapy and 3 patients were given supportive care. Nodal dissection was done for 10 patients 7 patients during primary surgery and 3 patients for regional nodal recurrence. Four patients developed recurrence-2 patients regional nodal recurrence, 1 patient-local and regional nodal recurrence and 1 patient-systemic recurrence. Overall survival rate(OS) is 74 % at 5 years. StageI-OS-75 %, stage II-OS-64 %, stage III –OS-60.6 %stage IV- OS-12 %. Conclusion: In our series, the incidence of cutaneous melanoma was much lower (0.05 %). Acral regions were the most common location in our population (72 %). Higher T stage with ulceration was common. Age and stage were important prognostic variables.

ER 052

A review on our experience on reconstruction of maxillectomy defects, surgical complications and Outcomes

Amritha*, Ganesh MS**, Udaykarjol*, Sriphani C*, Ajay CV*,Vasureddy C**, Sangireddy N**

Department of Surgical Oncology, VIMS&RC, BLR 66, Karnataka, India.

Aim: To evaluate the complications and outcomes following various reconstructive methods following various forms of maxillectomies Methods: We performed a retrospective analysis of medical records of patients who underwent various forms of maxillectomies from Jan 2011 to dec 2013. Postmaxillectomy defects were managed by either prosthesis or local flaps. Results: Forty patients had underwent various forms of maxillectomies. Fifteen patiens had undergone Browns class 1a maxilectomy as a component of gingivobuccal cancers extending to upper alveolus wherein a bite resection was performed. All of these patients underwent reconstruction with Pectoralis major myocutaneous flap. Ten patients underwent class 2a maxillectomy wherein they underwent reconstruction with Obturator and Split skin thickness grafting. Nine patients underwent class 3a-b resection and reconstruction with Temporalis myofascial flap reconstruction. Four patients underwent class 4a-b resection and reconstruction with temporalis myofascial flap. Two patients underwent Orbitomaxillary resection with palate preserved and reconstruction with temporalis myofascial and for head flap. Two patients who underwent orbitalexenteration developed nasocutaneous fistula which were reconstructed with forehead flap. One patient had partial loss of temporalis flap, one had postoperative epiphora due to ectropion which were managed conservatively. Mean follow up period was 8 months (Range 6–24 months). Two patients developed moderate grade of trismus after completion of radiotherapy. One patient developed recurrence in neck after 6 months of completion of adjuvant radiotherapy. All had moderate to fair speech and eating function. Conclusion: There was no difference between flap reconstruction or obturator intervention of maxillary defects in speech and eating function. Small and lateral defects are better reconstructed with obturator and defects involving orbit and total maxilla are better reconstructed with flaps.

ER 053

A retrospective study of 20 cases of Marjolin’s ulcer in a Tertiary Care Hospital.

Dr. Hemanth G N, Dr. Suraj Manjunath, St John’s Medical College Hospital, Bangalore.

Aim: To evaluate the clinicopathological presentation and treatment outcome of Marjolin’s ulcer. Materials & methods: Retrospective, Study period: 7 years- January 2007 to April 2014. Twenty consecutive patients with histologically confirmed Marjolin’s ulcer were studied. Information retrieved from medical records included demographic data, causative previous lesions, latency period, duration of illness, anatomical site, histology, treatment, complications, length of hospital stay and outcomes. Results: Of the 20 patients studied, male to female ratio was 5.6:1. In 8 (40 %) patients, burn scars were the most frequent predisposing factor while venous ulcer was found to be the next most frequent (3, 15 %). The most common site was lower limb, 12 (60 %) and in 3 (15 %) it was on head & neck and upper limb each. The average time from primary cause to change noticed was 12.3 years (1.5–37 years), change noticed to first consultation was 9.2 months (3–18 month) and first consultation to diagnosis was 5.6 months (0–15 months). Average number of biopsies required for diagnosis was 1.4 (1–4 biopsies). Squamous cell carcinoma was the only histology noted with no lymph node or distant metastasis in any of the cases in our study. Wide local excision was the most common modality of treatment and no locoregional recurrences noted in follow up so far. Conclusion: Marjolin’s ulcers are not rare in our clinical setting and commonly occur in burn scars that were left to heal secondarily. A high index of suspicion is required in the management of chronic non-healing ulcers and all suspected lesions should be biopsied. Early recognition and aggressive treatment of Marjolin’s ulcer is required for good outcome.

ER 054:

A case study of remission of re-current stage 4 B Cervical carcinoma by changing diet and lifestyle pattern

Nikhil Chaudhary, H. M. Pandey, SRM university, CEO- Madras Institute of Mind, 5 North Main Road, Annanagar West Extension, Chennai 600 101, Email: nikhilchaudhary86@gmail.com

Aim: To restrict the growth of cancer and convert it into a ‘cancer without disease’ or remission by changing dietary patterns in case of a single patient suffering from metastasized stage 4 b cervical carcinoma(recurrence or residual). Methods: The patient was suffering from hypermetabolic metastasized stage 4B cervical carcinoma (recurrence/ residual). A dietary and lifestyle regimen was prepared for the patient to follow based on three scientific principles to convert cancer into ‘Cancer without disease’. First being the anti angiogenesis and immune boosting property, second one being the control of Warburg effect and the third was to create a stress situation for the cancer cells to undergo apoptosis/ cell ingestion. There were certain complications which aroused and various difficulties faced by the patient which were overcome and positive results were obtained. Results: The MRI taken for the patient reveals remission in cancer resulting in improved quality of life. Conclusion: Nutrition and lifestyle play a vital and important role in the proliferation as well as control and remission of cancer. We propose certain interlinked hypothesis in our case study which can be further investigated by the experts to establish more credibility and give a whole new dimension to cancer treatment where nutrition and lifestyle can be made a complimentary therapy along with other treatment therapies like Surgery, Chemo Therapy, Radio Therapy, Brachy Therapy, etc. These changes have been found to compliment the conventional treatment by giving better results and improving the quality of life of the patient by reducing their suffering.

ER 055

Rare renal tumor: Tissue diagnosis is must.

Dr. Basant Kumar Department of Pediatric Surgery, SGPGIMS, Lucknow, U.P. India. Email: drbasant189@gmail.com

Background: In malignant renal masses, Wilms’ tumor accounts for almost 85 % cases while other rare renal tumors including stromal tumors constitute only 15 % of all pediatric renal masses. These rare tumors are usually aggressive and have similar presentation and radiological features as Wilms’ tumor and are very difficult to differentiate. Differentiation is important because each tumor has different chemotherapy protocol. Definite tissue diagnosis is essential for better outcome. Experience with clear cell sarcoma and primitive neuro-ectodermal tumor (PNET) of kidney presented here. Purpose: To present our difficulties in the diagnosis and treatment of clear cell sarcoma and primitive neuro-ectodermal tumor (PNET) of kidney in children. Method: Seven year female sick patient, admitted with large abdominal mass and distension with features of sub acute bowel obstruction. She has fever and gross hematuria. Multiple tru-cut biopsies were tried but tissue was inadequate and suggested small round cell tumor. In spite of low general condition of patient, open incisional biopsy was taken that confirmed the diagnosis of PNET tumor. Other 2 year male child presented with large abdominal mass with distension and discomfort. Multiple tru-cut biopsies were needed for definitive diagnosis of clear cell sarcoma. Result: There was good response after neo-adjuvant chemotherapy and mass was excised along with right kidney in both the children. Both are doing well without local or distant metastasis from last 1 year. Conclusion: These rare tumors usually present late because of their aggressive nature and early metastasis. They should be treated promptly. Definite tissue diagnosis (either tru-cut or open biopsy) is essential for better outcome. They should not be differentiated on the basis of their clinical and imaging features. Key-Words: Clear cell sarcoma; PNET; Renal mass.

ER056

FIRE DURING SURGERY: DANGERS IN MODERN SURGERY

N Kannan, Rashmi Dutta. Dept of Surgical Oncology and Anaethesiology, Army Hospital (R&R), New Delhi 110010

Introduction: Fire in operating room environment is a dangerous but fortunately rare event which reported infrequently. It poses a significant threat to health care providers and patients alike. Safety regulations often cover most engineering issues which may cause fire or minimise risk of a potential fire hazard. We report one such case which occurred during a surgical procedure with aim to sensitize surgeons of the possibility of the same and potential for instituting safety systems to prevent such occurrences. Case report: A 62 year old lady diagnosed case of Esophageal carcinoma was intubated with a double lumen tube for a planned radical esophageal resection. During the right thoracotomy as soon as the pleura was entered the operating surgeon’s glove caught fire ingnited by the contact of inflammable anaesthetic gasses and the spark of electrocautery. This led to immediate halt of the procedure to extinguish the fire on the surgeons fingers. Subsequently exploration revealed a rent in the trachea resulting from the endotracheal tube and pneumomediastinum. Esophagectomy was completed and trachea repaired by primary closure buttressed with an intercostals muscle flap. Post op recovery was uneventful.

ER 057

Tracheal Injury: Surgical Management

Kannan N, Gupta S, Dutta R., Army Hospital (R&R) New Delhi.

Introduction: Tracheal Injuries are uncommon and often reported during surgical procedures for lung and esophageal cancers. We report here our experience over 8 years of 6 cases of tracheal injury occurring during surgery of esophageal cancer and their successful management. Patients, observations and methods: During a period of 8 years we encountered 5 cases of tracheal tear occurring in cases of carcinoma esophagus undergoing surgery. In 5 cases the cause of tracheal injury was the result of overinflation of the cuff of the endotracheal tube. The injury was detected by the presence of subcutaneous emphysema in one and mediastinal emphysema at thoracotomy in all. In one case the tear was the result of dissection injury during a transhiatal dissection of the esophagus detected during surgery by sudden loss of airway control which was corrected by inflation of the bronchial cuff of the DLT and isolation of the right lung. In all cases the esophageal resection was completed and tracheal repair effected by direct suture of the membranous trachea and reinforcement by a vascularised intercostals muscle flap. Post operative ventilation was institute for 2 days and all patients made an otherwise uncomplicated recovery. Discussion: Tracheal injury is an uncommon event at surgery usually resulting from direct invasion of the disease into the airway. Iatrogenic tracheal injury due to intubation is uncommonly reported. The etiology of intubation injury is due to direct trauma and over inflation of the cuff of the endotracheal tube. Tracheal injury leads to loss of ventilation and leak of air into the mediastinum. This often necessitates urgent thoracotomy and manual obliteration of the rent and isolation of the lung to achieve single lung ventilation. Dissection of the esophagus from the posterior aspect of the trachea exposes the anatomy of the tracheal defect and possibility of direct repair. The posterior membranous wall of trachea is a thin muscular layer and direct repair often is tenuous and not strong enough to be able to sustain the stress of post operative tussive efforts. In addition the vascularity of the tracheal wall is compromised as a result of the dissection and injury. Hence new tissue in the form of muscle, pleura or pericardium is necessary to buttress the repair and allow effective healing. Use of latissmus dorsi muscle, diaphragm, strap muscles, sternomastoid muscles and intercostals muscle are described. Very often the process of thoracotomy makes this muscle unavailable for use in tracheal repair. The intercostal muscle provides the best locally available vascularised muscle flap for repair which has sufficient length to repair the entire length of the trachea. In our experience the intercostal muscle was used in all cases with good outcome. The operative steps of the surgical procedure will be presented.

ER 058:

Primary chest wall neoplasm’s: Resection and Reconstruction: our experience

Sriphani. P¹, Ganesh M.S², Sangi Reddy. N³, Vasu Reddy. C⁴, Ajay Chanakya. V⁵ Department of Surgical Oncology, Vydehi institute of medical sciences, #82, EPIP area, Whitefield, Bangalore-560066.

Aim: To study the techniques used for reconstruction after resection and the complications occurring in chest wall reconstruction after resection of musculoskeletal tumors and to identify the optimal reconstruction method for different clinical situations. Methods: A prospective observational study was performed over 1 year and mean follow up period was for 6 months. Ten patients underwent chest wall resection. Reconstruction was done with either of these-muscle flap, mesh or poly methyl methacrylate as required. Results: Of 10 patients 6 were male and 4 were female. Of those 5 patients had chondrosarcoma, pancoast’s tumour in one patient, 2 patients each of Ewing’s sarcoma and PNET. Patients with PNET/ Ewings sarcoma received preoperative chemotherapy followed by surgery and adjuvant chemo radiotherapy. Two patients underwent scapulectomy, one patient underwent claviculectomy, one patient lobectomy with chest wall resection, one patient sternal resection with reconstruction, and 5 patients underwent chest wall resection with reconstruction. One patient had superficial flap necrosis which was excised and resutured. Here we would like to describe our protocol in planning chest wall reconstruction. Conclusion: Neo-adjuvant treatment helps in downsizing and decrease the extent of resection in Ewing’s sarcoma/PNET. A well planned resection and reconstruction helps in Ro resection and decrease the postoperative complications.

ER 059

Evaluation of the role of⁶⁸Ga-DOTATOC PET CT scan and¹⁸F-fluorodeoxyglucose (FDG) PET CT scan in preoperative evaluation of patients with suspected broncho-pulmonary carcinoid tumours

Balasubramanian venkitaraman, Arvind Kumar & Rakesh Kumar

Cancer Institute(WIA), Chennai, Institute of Robotic Surgery, Sir Ganga RamHospital, New Delhi, Department of Nuclear Medicine, AIIMS, New Delhi. E mail: balapsgimsr@gmail.com,

Aim: To evaluate and compare the role of ⁶⁸Ga-DOTATOC positron emission tomography / Computerized tomography (PET/CT) scan and ¹⁸F-fluorodeoxyglucose (FDG) PET/CT scan in preoperative evaluation of patients with suspected pulmonary carcinoid tumour. Methods: It is a prospective observational study, a total of 32 patients with clinical suspicion of bronchopulmonary carcinoid tumours were included after taking informed written consent, were evaluated with ⁶⁸Ga-DOTATOC PET CT and ¹⁸F-FDG PET CT. The nuclear imagings of findings were compared, considering histopathological tissue diagnosis as gold standard. Results. Of the 32 patients, 26 patients had carcinoid tumours on histopathological diagnosis, 21 typical carcinoid(TC) and 5 atypical carcinoid(AC). ⁶⁸Ga-DOTATOC PET CT showed significant uptake in all the 21 TC and in 4/5 AC. ¹⁸F-FDG PET CT showed increased uptake in all 5 AC, while 8 of 21 TC showed no uptake. Sensitivity, Specificity and accuracy of ⁶⁸Ga-DOTATOC PET CT and ¹⁸F-FDG PET CT were 96.15, 100, 96.87 % and 78.26, 11.1, 59.37 % respectively in predicting the presence of carcinoid tumour preoperatively. In addition, ⁶⁸Ga-DOTATOC PET CT demonstrated additional lesions in mediastinal lymph nodes in one AC, not seen on ¹⁸F-FDG PET CT. Conclusion. ⁶⁸Ga-DOTATOC PET CT was found to be an effective investigation in diagnosing the presence of bronchopulmonary carcinoid preoperatively and also helps in detecting the presence of metastatic spread. ¹⁸F-FDG PET CT suffers a low sensitivity and specificity in preoperative diagnosis of carcinoid tumours. Absence of uptake on ⁶⁸Ga DOTATOC PET CT, practically rules out the possibility of typical carcinoid, according to our study.

	68Ga DOTATOC/PET-CT	18F FDG/PET-CT
Sensitivity	96.15 % (58.7–99.8 %)	78.26 % (46.2–94.9)
Specificity	100 %(59.1–100)	11.1 %(3.4–47.5)
PPV	100 %(71.5–100)	69.23 %(42.1–85.2)
NPV	85.71 %(29.4–99.2)	16.6 %(6.4–61.5)
Accuracy	96.87 %	59.37 %

ER 060

Giant exophytic renal angiomyolipoma mimicking as retroperitoneal sarcoma; a case report with review of literature

1. Dr Channabasappa kori, Naseem Akhtar, Vijay kumar MS, M Ch, Dept of surgical oncology, King George medical college, Lucknow

Abstract: Renal angiomyolipoma (AML) is an extremely rare condition. It arises from the mesenchymal element of the kidney. AML may occur as isolated finding or in association with tuberous sclerosis. Here we describe a rare case of giant exophytic renal angiomyolipoma in a 28 year old lady who presented with upper abdominal pain and palpable lump in left side of abdomen. Computed tomography of the abdomen and pelvis revealed large well defined mass in left side of abdomen with predominantly fat component and had ill defined interface with lower pole of left kidney. Metastatic work-up was negative. Patient underwent laparotomy with a preoperative diagnosis of retroperitoneal liposarcoma. Laparotomy revealed large mass arising from lower pole of kidney and a diagnosis of AML was made. Partial nephrectomy with enbloc resection of the mass was done. Histological examination of the biopsy revealed angiomyolipoma. Postoperative course was uneventful. Patient is disease free at 14 months of follow up. The present case emphasizes the need for better detection, further analysis and evaluation of such rare cases to identify their clinical course, ability to differentiate from retroperitoneal sarcoma and effective treatment options. Key words: Angiomyolipoma, kidney, retroperitoneal sarcoma.

ER 061:

TESTICULAR TUMOUR PRESENTING AS ABDOMINAL MASS-A CASE SERIES

Satish Kumar^1*, R.G. Baxla², M. Mundu³, C.P. Sinha³, R. C. Besra⁴, B. M. Baski⁴, OM Prakash¹, Sumegha Rana¹

Department of General Surgery, Rajendra Institute of Medical Sciences, Ranchi-834009 Email-satishktiwari01@yahoo.in

Aim-To study the various presenting features, diagnosis, treatment modalities and outcome of testicular tumour. Methods-Case Series:-Retrospective analysis of 10 patients was done who presented with abdominal mass and diagnosed to have testicular tumour. Results-Majority of the patients were below 35 years of age and the most common type of tumour seen was mixed type followed by pure seminoma. The diagnosis was made with the help of both radiological and biochemical parameters. High inguinal orchidectomy followed by adjuvant chemotherapy was the most common reatment modality used. Conclusion- Testicular tumors are the most common solid tumors in young adult males. Patients with testicular tumor often present with painless scrotal mass. Rarely, symptoms are related to metastases. Some of the patients present with abdominal mass due to retroperitoneal lymphadenopathy. Therefore in case of abdominal mass, one should always keep in mind the testicular malignancy as the differential diagnosis.

ER 062:

Pneumonectomy for lung cancer: indications and outcome in Indian scenario.

Dr Swati agrawal, Dr Dharma Ram, Dr. Ashish goel, Dr Shubha garg, Dr. Veda Padama Priya Selvakumar, Dr. Kapil Kumar,

DN Department of Surgical Oncology, Rajeev Gandhi Cancer Institute and Research Centre,

Sector-5 Rohini, New Delhi. E mail: Drswati2002@gamil.com

Aim: Surgical treatment for lung cancer has evolved from pneumonectomy, lobectomy to sleeve resection around the world. However pneumonectomy still holds a major share in surgery for lung cancer in developing countries. The aim of the study was to analyse the demographic and clinicopathologic profile and factors determining type of surgery at a tertiary care cancer hospital in north India. Methods: We retrospectively analysed records of patients who underwent surgery for lung tumors at our institute from Jan 2011 to April 2014. Demographic factors, comorbidities, presenting symptoms, staging, preoperative treatment, surgical and histopathological details, postoperative complications and follow up were analyzed. Results: From Jan 2011 to April 2014; fifty patients underwent surgery for lung cancer at our institute. Mean age at presentation was 53.75 years with male predominance (40:10). Eighty percent patients were symptomatic at presentation while rest were detected either on screening or surveillance imaging. Out of 45 primary lung cancer patients, seventy five percent patients had locally advanced disease. Twenty eight patients underwent lobectomy, 20 underwent pneumonectomy and 2 had non-anatomic resections. Histology revealed adenocarcinoma (23), squamous cell carcinoma (20), sarcoma (3), NET (3) and hamartoma in one. All patients had R0 resection except for involved bronchial margin in three and vascular margin in 1 patient. Five patients had major postoperative complications, 3 improved after conservative management but 2 succumbed to the disease. Conclusion: In the Indian scenario, as majority of lung cancer patients present at advanced stage, pneumonectomy still holds a major position in its management and acceptable postoperative outcome can be achieved with aggressive peri-operative management.

ER 063

Preoperative chemotherapy followed by surgery for locally advanced lung cancer is feasible and safe.

Dr Swati Aggarwal, Dr Shubha Garg, Dr Ashish Goel, Dr Dharma Ram Poonia, Dr Veda Padama Priya, Dr Kapil Kumar

Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre. Sector -5, Rohini, New Delhi-85Email: shubha_mbbs99@yahoo.com

Aim: To study the demographic pattern, clinicopathological profile and management strategy of patients undergoing resection for lung cancer after neoadjuvant therapy at a tertiary care cancer centre in India. Methods: We retrospectively analyzed records of patients who underwent surgery for lung cancer after neoadjuvant therapy at our institute from Jan 2011 to April 2014. Demographic factors, co morbidities, presenting symptoms, staging, preoperative treatment, surgical and histopathological details, postoperative complications and short term follow up were analyzed. Results: From Jan 2011 to April 2014; 50 patients underwent surgery for lung cancer (lobectomy/pneumonectomy/non-anatomical lung resections) at our institute. Mean age at presentation was 53.75 years (40 males and 10 females). Eighty percent patients were symptomatic at presentation. Out of 50 pts, 24 patients received preoperative chemotherapy while one got preoperative concurrent chemoradiation. Of 25 pts receiving neoadjuvant treatment, there were 13 pts with stage IIIB, 7 with stage IIIA and 5 with stage II disease. Fourteen patients underwent pneumonectomy, 3 underwent bilobectomy and 8 underwent lobectomy. Four patients required enbloc rib resection for contiguous chest wall invasion. Post operative histopathology revealed residual primary disease in all patients undergoing surgery. Only one patient had positive bronchial margin. Overall 18 pts had complete response in nodal disease, 5 patients were pN1 and 2 were pN2 on histopathology. Three patients had major postoperative complications with one 30 day perioperative mortality. Conclusions: In the Indian setup, majority of lung cancer patients present at advanced stage requiring neoadjuvant therapy. In our experience surgery after neoadjuvant treatment is feasible and a safe option with acceptable morbidity and mortality.

ER 064

FIRE DURING SURGERY: DANGERS IN MODERN SURGERY

N Kannan, Rashmi Dutta.

Dept of Surgical Oncology and Anaethesiology

Army Hospital (R&R), New Delhi 110010

Introduction: Fire in operating room environment is a dangerous but fortunately rare event which reported infrequently. It poses a significant threat to health care providers and patients alike. Safety regulations often cover most engineering issues which may cause fire or minimise risk of a potential fire hazard. We report one such case which occurred during a surgical procedure with aim to sensitize surgeons of the possibility of the same and potential for instituting safety systems to prevent such occurrences. Case report: A 62 year old lady diagnosed case of Esophageal carcinoma was intubated with a double lumen tube for a planned radical esophageal resection. During the right thoracotomy as soon as the pleura was entered the operating surgeon’s glove caught fire ingnited by the contact of inflammable anaesthetic gasses and the spark of electrocautery. This led to immediate halt of the procedure to extinguish the fire on the surgeons fingers. Subsequently exploration revealed a rent in the trachea resulting from the endotracheal tube and pneumomediastinum. Esophagectomy was completed and trachea repaired by primary closure buttressed with an intercostals muscle flap. Post op recovery was uneventful.

Discussion: Fires in operating room environment are a preventable dangerous event. The common myths associated with this even are:

1. OR fires do not happen in today’s hospitals;

2. if fires do occur, they were not preventable;

3. fires only occur at inferior facilities; and

4. all staff in the OR know what to do if a fire occurs.

Nothing could be more far from the truth in this matter. Emergency Care Research Institute study published in 2009 lists surgical fires in the top 3 of technology related fire incidents with approximately 550–600 events annually in the USA. (ECRI Institute. 2010 top 10 technology hazards. https://www.ecri.org. Health Devices. 2009;38(11).). Surgical fires are associated with electrosurgical equipment in 2/3 cases and often in procedures relating to face head and thorax. (“Preventing surgical fires,” Sentinel Event Alert 29 (June 24, 2003)http://www.jointcommission.org/sentinel_event_alert_issue_29_preventing_surgical_fires/.) Fire results from close proximity of a fuel eg. Alcohol swabs, anaesthetic gasses, igniter eg. Laser and electrocautery and a propagator eg. oxygen. OR fires may be subdivided into

1. fires occurring on the patient and

2. fires occurring in the OR environment.

The surgeon is usually the first to recognize the former. Immediate source control by smothering the fire or dousing with saline followed by removing burning/charred material is essential. In case os airway fires during endiscopic procedures immediate extubation followed by reintubation with a fresh tube is recommended. Additionally the propagators such as oxygen and nitrous oxide need to be shut off till fire in controlled. In case of OR environment fires the protocol directed by the oft repeated acronym RACE is recommended. Fortunately in our case there was no burn to the patient and the positive pressure of the pneumothorax rapidly discharged the flammable gasses. The only object which caught fire was the surgeons latex gloves and resulted in a 1st degree burn on his fingers. The event brings to light a rare but dangerous event which requires us to be aware of its occurrence and be prepared for its prevention and treatment.

ER 065

Primary chest wall neoplasm’s: Resection and Reconstruction: our experience

Sriphani. P¹, Ganesh M.S², Sangi Reddy. N³, Vasu Reddy. C⁴, Ajay Chanakya. V⁵ Department of Surgical Oncology, Vydehi institute of medical sciences, #82, EPIP area, Whitefield, Bangalore-560066.

Aim: To study the techniques used for reconstruction after resection and the complications occurring in chest wall reconstruction after resection of musculoskeletal tumors and to identify the optimal reconstruction method for different clinical situations. Methods: A prospective observational study was performed over 1 year and mean follow up period was for 6 months. Ten patients underwent chest wall resection. Reconstruction was done with either of these-muscle flap, mesh or poly methyl methacrylate as required. Results: Of 10 patients 6 were male and 4 were female. Of those 5 patients had chondrosarcoma, pancoast’s tumour in one patient, 2 patients each of Ewing’s sarcoma and PNET. Patients with PNET/ Ewings sarcoma received preoperative chemotherapy followed by surgery and adjuvant chemo radiotherapy. Two patients underwent scapulectomy, one patient underwent claviculectomy, one patient lobectomy with chest wall resection, one patient sternal resection with reconstruction, and 5 patients underwent chest wall resection with reconstruction. One patient had superficial flap necrosis which was excised and resutured. Here we would like to describe our protocol in planning chest wall reconstruction. Conclusion: Neo-adjuvant treatment helps in downsizing and decrease the extent of resection in Ewing’s sarcoma/PNET. A well planned resection and reconstruction helps in Ro resection and decrease the postoperative complications.

ER 066

Preoperative chemotherapy followed by surgery for locally advanced lung cancer is feasible and safe.

Dr Swati Aggarwal, Dr Shubha Garg, Dr Ashish Goel, Dr Dharma Ram Poonia, Dr Veda Padama Priya, Dr Kapil Kumar, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre. Sector -5, Rohini, New Delhi-85 Emails: shubha_mbbs99@yahoo.com, dr_ashishgoel@gmail.com

Aim: To study the demographic pattern, clinicopathological profile and management strategy of patients undergoing resection for lung cancer after neoadjuvant therapy at a tertiary care cancer centre in India. Methods: We retrospectively analyzed records of patients who underwent surgery for lung cancer after neoadjuvant therapy at our institute from Jan 2011 to April 2014. Demographic factors, co morbidities, presenting symptoms, staging, preoperative treatment, surgical and histopathological details, postoperative complications and short term follow up were analyzed. Results: From Jan 2011 to April 2014; 50 patients underwent surgery for lung cancer (lobectomy/pneumonectomy/non-anatomical lung resections) at our institute. Mean age at presentation was 53.75 years (40 males and 10 females). Eighty percent patients were symptomatic at presentation. Out of 50 pts, 24 patients received preoperative chemotherapy while one got preoperative concurrent chemoradiation. Of 25 pts receiving neoadjuvant treatment, there were 13 pts with stage IIIB, 7 with stage IIIA and 5 with stage II disease. Fourteen patients underwent pneumonectomy, 3 underwent bilobectomy and 8 underwent lobectomy. Four patients required enbloc rib resection for contiguous chest wall invasion. Post operative histopathology revealed residual primary disease in all patients undergoing surgery. Only one patient had positive bronchial margin. Overall 18 pts had complete response in nodal disease, 5 patients were pN1 and 2 were pN2 on histopathology. Three patients had major postoperative complications with one 30 day perioperative mortality. Conclusion: In the Indian setup, majority of lung cancer patients present at advanced stage requiring neoadjuvant therapy. In our experience surgery after neoadjuvant treatment is feasible and a safe option with acceptable morbidity and mortality.

ER 067

A PROSPECTIVE NON-RANDOMISED STUDY OF TOTAL ROBOTIC 3 STAGE ESOPHAGECTOMY FOR CARCINOMA ESOPHAGUS-EARLY INDIAN EXPERIENCE.

Dr. Rohit kumar c, Dr. Somashekhar SP, Dr. Shabber S Zaveri, Dr. Rajshekhar Jaka, Dr. Monika Pansari, Dr. Prasanna G

Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore

Aim: To study the feasibility and outcome of robotic assisted 3 stage esophagectomy in cases of carcinoma esophagus. Methods: There were 21 patients included in the study till date who were diagnosed with esophageal carcinoma. Patients with locally advanced disease were first treated with neoadjuvant chemo-radio-therapy and then assessed for response and taken up for surgery. Patient were operated with the Da Vinci robotic operating system. First thoracic part in prone position and then abdominal and then left neck anastomosis in supine position. Pyloroplasty and feeding jejunostomy was made to all patients. Patients were followed up for complications and recovery. The median follow-up period Results: Among 21 patients, 9 were males and 12 females. Median age of patient was 55 years (<40–>70) and more than 60 % of patients had more than one co-morbid illness. Median operating time of procedure including docking was 360 min (range from 260 to 480). As per protocol all patients were observed in ICU for 1 day only 2 patients needed ventilation for first 24 h. Feeding was initiated through FJ tube in all patients within 12 h, oral feeds started on 6th day in all. Only 2 patients needed para-enteral analgesics beyond 72 h with all ambulated the next day itself except for 2. None of the patients had anastomotic or chylous leak, 2 had sub-cutaneous emphysema which settled by 3rd day, one patient had voice change which recovered after 4 weeks, 1 patient had pneumonitis and 2 had paralytic ileus. On histopathological examination proximal, distal and CRM margins were negative for all and median lymph nodes harvested was 32(range 13–48). Conclusions: Total robotic esophagectomy is technically feasible as assessed by the completeness of surgery in form of negative margins and lymph nodes harvested and ease of thoracic mobilization and forming of stomach tube. Minimal morbidity and very less pulmonary complications, less pain, better recovery even in aged patients with significant comorbidities indicates the usefulness of robotic surgery in carcinoma esophagus.

ER 068

Comparison of three different ‘Risk of malignancy indices’ in diagnosis of pelvic masses in Indian population.

Uday Karjol^*, MS Ganesh^**, Amrutha VRS^*, Sriphani P^*, Ajay CV^*, Vasureddy C^**, Sangireddy N^**.^* - Resident, ^**- Consultant, Department of Surgical Oncology, Vydehi Institute of Medical Science, EPIP Bangalore 66, Karnataka, India.

Aim: The aim of the study is to evaluate the ability of 3 different risk of malignancy indices (RMI 1,2,3) in differentiating benign from malignant pelvic mass incorporating menopausal status, serum CA 125 levels and ultrasound findings. Methods: This is a retrospective study of 120 women admitted in the department of surgical oncology for evaluation of pelvic mass between January 2011 and May 2014. To differentiate benign versus malignant ovarian mass, the sensitivity, specificity, positive and negative predictive values of ultrasound findings, serum CA 125 and menopausal status were taken separately and combined into risk malignancy index 1,2,3. Results: Using the cut off value of 200 to indicate malignancy; Risk of malignancy index 1 and 3 had similar sensitivity, specificity, positive predictive value, and negative predictive value 73.68, 90.9, 93.33, 66.66 % respectively. Risk of malignancy index 2 had sensitivity of 84.21 %, specificity of 66.3 %, positive predictive value of 80 % and negative predictive value of 70 %. Conclusion: ‘Risk of malignant indices’ were able to differentiate between benign and malignant pelvic masses in significant number of patients. RMI 2 was more sensitive in predicting malignant pelvic masses and is suitable for our population.

ER 069

Laparoscopy Vs. Open Surgery for Surgical Treatment of Uterine Cancer- A Retrospective Study

Aim: The retrospective study aims to compare laparoscopy versus laparotomy for surgical management of uterine cancer. Materials and Methods: Outcomes of patients of low risk groups with clinical stage I to IIA uterine cancer treated surgically by hysterectomy, salpingo-oophorectomy and pelvic lymphadenectomy were analysed. The main study end points were 6-week morbidity and mortality, hospital length of stay and conversion from laparoscopy to laparatomy. Results: A total of 95 patients with carcinoma of endometrium were treated surgically (04/2008 to 04/2013). Patients who were found to have advanced disease were excluded from the study. Laparoscopy or Laparoscopic Assisted Vaginal Hysterectomy (LAVH) surgery was initiated in 63 patients, but conversion was done in 8 patients. Conversion from laparoscopy to laparotomy was secondary to poor visibility in 2 patients, surgical causes in 4 patients and anesthetic causes in 2 patients. Rate of conversion reduced with increasing surgical experience and better patient selection. Four patients who underwent open surgery had wound complications (1 major), while 1 patient had lower limb weakness. One patient with LAVH had urinary retention, and 1 patient had urinary leak. Average lymph nodes retrieved laparoscopically was 9.33 (range 3 to 20), and average lymph nodes retrieved by open method was 10.84 (range 4 to 25). While laparoscopy had significantly more operating time, duration of hospital stay was significantly more in open patients.(median 2 days vs. 5 days.). Though blood loss was more in open surgery, transfusion requirement remained the same. Conclusion: Laparoscopic surgical treatment for uterine cancer is safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Results tend to improve with experience. Follow-up of these patients will determine whether surgical technique impacts pattern of recurrence or disease-free survival especially with respect to lymph node dissection.

ER 070

Malignant ovarian germ cell tumour – a single institute experience

Dr. Praveen Ravishankaran, Surgical Oncology Resident, Cancer Institute, Adyar, Chennai. Ph No: 9894125953, Email ID: preveen264@gmail.com

Aim: To evaluate the clinicopathological prognostic factors in malignant germ cell tumours diagnosed at a single institute over a period of 5 years. Methods: We reviewed the medical records of 58 patients treated from 2007 to 2011 at our institiute. Clinical data including demographics, stage, surgery, chemotherapy, survival, and fertility were collected from patient’s file. Results: Median age was 20 years (range, 1–71). The histologic subtypes included 17 dysgerminomas, 17 mixed tumours, 15 yolk sac tumors, 4 immature teratomas, 4 mature teratomas and 1 embryonal carcinoma. The most common component in mixed type tumours were yolk sac tumour and embryonal carcinoma (n = 7). The most common type of complaint was pain in about 83 % of the patients (n = 47). Sixty percent of the patients underwent some form of surgery elsewhere following which they were reffered to our institute. Thirteen patients underwent primary surgery, while 45 patients received upfront chemotherapy. Six patients underwent fertility sparing surgery and an equal number of patients underwent staging laparotomy. After neoadjuvant chemotherapy, 26 patients underwent subsequent surgery. On histopathological examination, 21 patients had no evidence of residual disease, while 3 patients had evidence of immature teratoma and 2 patients had mature teratoma. Cumulative overall survival and disease free survival were 91 and 86 % respectively. Stage was the most important prognostic factor with the overall survival (p = 0.03) and the disease free survival (p = 0.008) being statistically significant. By the end of the study period, 3 patients delivered healthy infants. No instance of second malignancy was noted among patients who received chemotherapy. Three patients developed severe pulmonary complications with bleomycin based chemotherapy. Conclusion: Germ cell tumours present with a myriad of histological subtypes, with the overall survival being among the best of the solid tumours. Like other solid tumour, the stage is the most important prognostic factor dictating survival of the patient. Fertility sparing surgery is the norm in all viable circumstances, as conception after treatment is a true possibility.

ER 071

PRE OPERATIVE CHEMOTHERAPY IN BULKY EARLY CERVICAL CANCERS

Prof. Rajaraman, Addl. Prof. Subbiah, Dr. Navin Noushad

Aim: Cervical cancer accounts for 26 % of cancer mortality in Indian females. Most of these are bulky early cancers. Definitive chemoRT remains the standard of care however equally effective radiation sparing multimodal treatment options like induction chemotherapy followed by surgery are emerging. We performed this prospective randomized trial to assess the efficacy of neoadjuvant chemotherapy in bulky early cervical cancers and to identify the ideal cisplatin based chemotherapy regime. Methods: 61 patients with bulky early cervical cancers (stage 1B2, 2A2 and 2 B) meeting the inclusion criteria were randomized in 1:1 ratio to a preoperative chemotherapy regime of cisplatin/5FU (arm A) or cisplatin /Taxol (arm B), all responding patients underwent radical hysterectomy and specimen subjected to pathological examination. All study patients were followed till the end of the study period (median 18 months). Results: The median age of the patients was 47 years. All patients had squamous cell histology with equal grade distribution. Sixty-three percent had stage 2 b disease. Overall operability rate was 72 %, 28 % were non responders (arm A 37 % vs arm B 18 %). Forty-seven percent achieved a complete pathological response in arm B compared to arm A (10 %). Radiation sparing was possible in 25 % of patients. Preoperative chemotherapy with cisplatin /Taxol leads to better response P < 0.028. There was no major chemotherapy related complications in either arms and no operative mortality. Two patients died of progressive disease during the study period. Conclusion: Preoperative chemotherapy for bulky early stage cervical cancers appears an exciting radiotherapy sparing treatment option in responsive patients. cisplatin /Taxol based chemotherapy is a safe and better effective regime for this clinical cohort. Larger multi institutional phase 3 studies are required to confirm these results .

ER 072

LATERALLY EXTENDED ENDOPELVIC RESECTION (LEER) – SURGICAL TREATMENT OF PELVIC WALL RECURRENCES OF GYNECOLOGICAL MALIGNANCIES

Objective: Pelvic Exenteration is salvage surgery for subset of patients with local recurrent or residual gynecological malignancies. This radical surgery may also be considered in locally advanced primary disease not suitable for radiotherapy. However high operative abortion and intralesional tumor resection rates significantly limits its clinical benefit. LEER is characterized by inclusion of the internal iliac vessel system, endopelvic part of the obturator internus muscle, coccygeus, iliococcygeus and pubococcygeus muscles into the exenteration specimen. Laterally extended endopelvic resection may achieve tumor free margins and improve locoregional control. The reported 5 years overall survival for LEER is 55 % and disease free survival is 62 %. Methods: Patients undergone laterally extended endopelvic resection between February 2012 and May 2014. The lateral resection plane of pelvic exenteration is extended to the medial aspects of lumbosacral plexus, sacropinous ligament, acetabulum and obturator membrane to achieve complete removal of tumors fixed to pelvic side to achieve free margins. Results: Total of 5 patients out of which 4 patients with recurrent cervical cancer and 1 patient with residual cervical cancer involving pelvic sidewall underwent LEER. All patients had received previous pelvic irradiation. Four patients underwent total pelvic exenteration with LEER and 1 patient underwent anterior pelvic exenteration with LEER. All 5 patients had tumor free margins including lateral margin. Four patients reconstructed with wet colostomy and 1 patient with ileal conduit. Two patients had wound complications and 1 patient had urinary leak for which ureteric reanastomosis done. Conclusion: Laterally extended endopelvic resection has potential to salvage patients to achieve wider margins in patients with locally advanced and recurrent gynecologic malignancies, including those with pelvic side wall disease, traditionally not considered for surgical therapy.

ER 073

TREATMENT OUTCOME OF CARCINOMA OF VULVA -10 YEARS EXPERIENCE FROM A TERTIARY CANCER CENTRE OF SOUTH INDIA

Rajaraman R,. Subbiah S, Sakthiushadevi. J, Centre for Oncology, Government Royapettah Hospital, Chennai

Introduction: Carcinoma vulva is constitutes 0.3 % of all cancers affecting the females and 1.3 % of all gynecological malignancies The present study was an retrospective analysis of epidemiological and clinical characteristics and treatment outcome of vulval cancer patients Materials and Methods: A retrospective review of all the patients who underwent surgery for invasive carcinoma of the vulva during a period of 10 years between 2003 and 2014 was carried out. Results: 39 patients were evaluated. The median age of the patients in our series was 55. Stage wise distribution of the cases include stage I 48.7 % stageII 0.07 % stageIII 38.4 % and stage IV 0.05 %.Of those 39 patients, 28 underwent Radical Vulvectomy with nodal dissection, 4 underwent Hemivulvectomy with nodal dissection, 2 underwent simple vulvectomy, 4 underwent Wide local exicision alone & 1 underwent Wide local excision with nodal dissection. Histopathology -all were squamous cell carcinoma Node positive with extra capsular spread (ECE) was 10.25 % and without ECE spread was 25.6 % Adjuvant radiation therapy [EBRT] was given to margin positive and node positive patients. At a median follow up of 26 months, the estimated Disease Free Survival(DFS) and 5 years Overall Survival(OS) for all the cases in our series was 65.4 % and 85.1 % respectively. Advanced stage and lymph node positivity and lymph node positivity with ECE have emerged as important prognostic factors that significantly affected estimated 5 years OS. The only factor that affected the DFS was ECE. Conclusion: The median age in our series was 55 years. Advanced stage, lymph node positivity and lymph node positivity with ECE have emerged as important prognostic factors that significantly affected estimated 5 years OS. Extracapsular nodal spread was observed as the only prognostic factor that significantly affected both OS and DFS on univariate analysis in our series.

ER 074

An unusual abdominal wall only recurrence in carcinoma ovary –a case report

Rajaraman R, Subbiah S, Sakthiushadevi. J Centre for Oncology, Government Royapettah Hospital, Chennai

Introduction Ovarian cancer remains the leading cause of death among gynaecologic cancers. Patterns of recurrence in ovarian carcinoma are well described and include peritoneal deposits, ascites, elevated CA 125 alone, omental deposits. This is a case report of an unusual isolated abdominal wall recurrence in a patient with carcinoma ovary. Case report We present a case of 60 year old female with ovarian mucinous adenocarcinoma stage Ibwho underwent staging laparotomy in August 2004, followed by 6 cycles of chemotherapy with paclitaxel and cisplatin. Her pre-treatment and post treatment CA 125 values were 467 and 15 IU/ml respectively. She developed incisional hernia in May 2008 for which mesh repair was done. Four months later in September 2008 she presented with abdominal mass. On examination she had 15 × 10 cm abdominal wall swelling No other lesion elsewhere. Her CA-125 was 10 IU /ml. Fine Needle Aspiration Cytology was done from the mass and was reported as ovarian mucinous adenocarcinoma. She underwent wide excision of the mass. Intraoperatively herentire peritoteum was found to be normal and no disease elsewhere. Now she is disease free and on regular follow up. Discussion Ovarian cancer usually spreads in a loco regional fashion to involve the peritoneal cavity and retroperitoneal nodes. It can occur outside the abdomen as well. The most common site is the pleura through trans diaphragmatic lymphatics. Isolated abdominal wall metastases of ovarian cancer with no secondaries elsewhere are very rare but not impossible. The probable cause in this case could be small microscopic residue within the peritoneum inside the hernialsac retained in the abdominal wall after the incisional hernia repair.

ER 075

COMPARISION OF CLINICAL EXAMINATION VERSUS EXAMINATION UNDER ANAESTHESIA IN LOCALLY ADVANCED CARCINOMA CERVIX – SINGLE INSTITUITIONAL REPORT.

R. Rajaraman. S. Subbiah. A. Joseph Stalin Antony Muthu

Background: Carcinoma cervix is staged clinically. Any bias in clinical examination will drastically alter the treatment modality as well as prognosis. EUA is not done routinely as part of clinical staging. Objective of this study was to determine the variability in staging by comparing clinical examination and EUA findings. Method: A prospective analysis of 62 patients with biopsy proven carcinoma cervix(Stage IB,IIA,IIB,IIIB) treated at Govt. Royapettah Hospital, Chenai between 2013 and 2014 is done. EUA and clinical findings are compared. Studied parameters include tumour size, involvement of parametrium, pelvic sidewall, adjacent organs and clinical staging and treatment modality. Results are analysed using Chi-Square test. Result: There is a high discordant value in 40 patients (60 %) with EUA being considered the standard. After EUA, Upstaging is noted in 14 patients, down staging is seen in 12 patients and variation in clinical finding without alteration of stage is noted in 14 patients. Treatment modality changed from surgery to radiotherapy in 3 patients and radiotherapy to surgery in 2 patients. Of the various parameters, parametrial variation is the highest.(50 %) Conclusion: Bias in clinical staging of carcinoma cervix is increased by relying only on clinical examination. Examination Under Anaesthesia is recommended in all cases for clinical staging of carcinoma cervix particularly for parametrial assessment.

ER 076

Oncocytic tumor of the adrenal cortex-a rare entity

Durga CK, Naskar D, Sharma D, Agarwal H

Aim: To review the presentation and diagnostic examination of adrenocortical oncocytoma Method: Case report from a tertiary care hospital (Dr. RML Hospital) of a 45 year old male who presented with a large intrabdominal lump 15*18 cm in size involving epigastric, left lumbar, left hypochondrium and umbilical region. Patient’s CECT abdomen was suggestive of left sided RCC with no invasion of blood vessels. Result: After preoperative evaluation and workup exploratory laporotomy with left side nephrectomy and splenectomy was done. Patient was discharged on 11th day in good condition after vaccination. Final histopathological report showed it to be oncocytic tumor of adrenal cortex origin. Conclusions: Oncocytes are tumor cells that are highly eosinophilic and granular due to prescence of large number of mitochondria. Oncocytomas are mostly located in kidney, thyroid, pararthyroid and salivary glands and are usually benign. Adrenal cortex oncocytomas are rare tumors (only 147 cases reported so far). They are more prevalent in women and more on left side. They are usually benign tumors and nonfunctioning. A few of the cases may present as functioning tumors hence biochemical analysis is important. They most frequently present as large intrabdominal mass. However, there is dilemma regarding its preoperative diagnosis as there is no characteristic CT or MRI finding. Histopathological examination can only provide definite diagnosis in these cases. They are strongly positive for vimentin, alpha-inhibin and melan A. They are well circumscribed and encapsulated and on cut section are yellow to tan brown in colour. Lin-Weiss-Bisceglia system is used to determine its malignant potential. Since they present as large mass surgical excision is mostly required. Smaller tumors can be dealt laporoscopically while large ones requires open approach. Role of other modalities (chemotherapy and radiotherapy) has not been studied well till date.

ER 077

Evaluation of response to neo-adjuvant Chemo-radiation in Rectal Cancer: Whether second MRI is really needed?

Mira Wagh, Iqbal Ahamed M, Iqbal Ahamed M, Regional Cancer Centre, Trivandrum. Phone-8943092461

Aim

• To study response of locally advanced rectal cancers to neo-adjuvant chemo-radiation

• To correlate response on MRI and pathology

• To predict mesorectal fascia involvement on pre-surgery MRI, thereby to predict circumferential margin positivity

Methods This was a prospective observational study. Fifty-six patients with T3, T4 and/or node positive rectal cancers on MRI, were included. Study period was from December 2011 to May 2013. Patients received 50.4 GY of radiation over 28 days and concurrent 5-fluoro-uracil infusion 500 mg/m² on first and last 3 days of radiation. Surgery was planned 6-8 weeks after chemo-radiation. MRI was repeated for restaging a week before surgery. We correlated 1) Stage on pre-surgery MRI with that on pathology & defined sensitivity, specificity & accuracy of MRI; 2) Response to chemoradiation on MRI with pathological response; 3) Mesorectal fascia involvement on pre-surgery MRI with circumferential margin positivity. Results Post chemo-radiation MRI had a sensitivity of 60.9 %, specificity of 88.4 % and accuracy of 84.8 % for T stage; sensitivity of 76.1 %, specificity of 89.3 % and accuracy of 84.8 % for N stage; sensitivity of 63 %, specificity of 89.4 % and accuracy of 83 % for composite stage; sensitivity of 84.85 %, specificity of 98.05 % and accuracy of 96.94 % for tumour regression grade; positive predictive value of 50 % and negative predictive value of 100 % for circumferential margin positivity. There was no significant difference in response seen on pre surgery MRI and on histopathology. However, second MRI did not lead to change in management in any patient. Conclusions MRI pelvis is a reliable investigation for assessing response to chemo-radiotherapy. However in absence of change in management, whether second MRI is needed for restaging is questionable. MRI has positive predictive value of only 50 % for circumferential margin positivity. In absence of better alternative, and considering the fact that circumferential margin positivity correlates with poor outcome, MRI pelvis may still be warranted for the same.

ER 078

MALIGNANT PERIPHERAL NERVE SHEATH TUMOUR OF SMALL INTESTINE PRESENTING AS ILEO-ILEAL INTUSSUSCEPTION -A CASE REPORT

Diwakar Pandey, Nihar Mohaptra, Ankur Verma, Om Prakash Pathania, Department of General surgery, Lady Hardinge Medical College, Bhagat Singh Road, New Delhi 110001, INDIA, Email-drdiwakarpandey@yahoo.in

Abstract- Malignant Peripheral Nerve Sheath Tumours(MPNST) arise from a Peripheral nerve or exhibit nerve sheath differentiation on Histology. Most common sites of occurrence are proximal portions of the upper and lower extremities and the trunk. Around 50 % of it are associated with Neurofibromatosis Type 1(NF1) with incidence of two to five per cent in patients with NF1. The estimated incidence in general population without NF1 is 0.0001 % of which Gastrointestinal MPNST are extremely rare. A 45 years lady without pathological antecedent for NF1 was admitted with pain in right lower abdomen & multiple episodes of vomiting for 3 months. Past History was irrelevant except for presence of controlled type 2 Diabetes Mellitus and Hypertension. On Examination she had tender Right Iliac Fossa. Preoperatively we diagnosed Intussusception in the small bowel by Ultrasonography and Contrast CT abdomen with characteristic target sign. On Lower midline Laparotomy, Ileo-ileal Intussusception(proximal ileum telescoping into distal ileum) was found 2 f. proximal to ileo-caecal junction with surrounding inflammed mesentery and presence of intraluminal tumour as lead point. Resection of involved segment of ileum along with its mesentery was done followed by ileo-ileal anastomosis. Histopathology was suggestive of High grade MPNST. Postoperative course and follow up for last month is uneventful.

ER 079

Giant omental fibromatosis presenting as pelvic mass

Dr Channabasappa kori, Pradyumn singh, Vijay kumar, Dept of surgical oncology King George medical college, Lucknow.

Abstract: Omental fibromatosis also termed as abdominal desmoids is a rare benign but locally aggressive neoplasm characterized by mass like or infiltrative growth of fibrous tissue. It usually arises from the abdominal wall or the extremities, however rarely it may also arise in the omentum, ileocolic mesentery, transverse or sigmoid mesocolon and ligamentum teres. Here we present an 18 years old male, who presented with lower abdominal pain and palpable lump in hypogastric region. Computed tomography of the abdomen and pelvis showed large heterogeneous mass in lower abdomen, possibly arising from mesentery with regional adenopathy. Metastatic work up was negative. Patient underwent exploratory laparotomy with preoperative diagnosis of mesenteric tumor possibly gastrointestinal stromal tumor [GIST]. Histopathological examination revealed the lesion as omental fibromatosis. Postoperative course was uneventful and is disease free at 18 months of follow up. To the best of our knowledge, very few cases of omental fibromatosis are noted in literature. Here we describe a rare case of giant omental fibromatosis which resembled mesenteric GIST based on clinical and radiological findings but finally diagnosed as fibromatosis by histomorphology and immunohistochemistry (IHC). The present article describes fibromatosis of greater omentum and difficulty in preoperative diagnosis, frequently misdiagnosed as gastrointestinal stromal tumors. Keywords: fibromatosis, omentum, mesentery, desmoids.

ER 080

High grade neuroendocrine carcinoma of the gall bladder- A rare entity

Channabasappa kori, Sameer Gupta & Vijay kumar, Dept of surgical oncology King George medical college, Lucknow

Abstract: Primary neuroendocrine carcinoma of the gall bladder (GB) is an extremely rare condition and is usually an incidental diagnosis. Here, we describe a rare case of primary gall bladder neuroendocrine carcinoma in a 30 years old lady who presented with upper abdominal pain and palpable lump in the right hypochondrium. Computed tomography of the abdomen showed an ill-defined heterogeneous soft tissue mass involving gall bladder and adjacent liver parenchyma with no obvious regional adenopathy. Metastatic work-up was normal and the patient underwent radical cholecystectomy. Histopathology and immunohistochemistry (IHC) study revealed high grade neuroendocrine carcinoma of the gall bladder involving the adjacent hepatic parenchyma. However, there was no evidence of clinical endocrinopathy. Patient received adjuvant chemotherapy and is disease free at 14 months of follow up. The present case emphasizes the need for better detection, evaluation and analysis of such rare entities, to identify their natural course and effective treatment modalities Key words: Neuroendocrine tumor, gall bladder, liver.

ER 081

SMALL BOWEL TUMORS: CLINICAL PRESENTATION, PROGNOSIS AND OUTCOME IN 12 PATIENTS IN A TERTIARY CANCER CARE CENTER OVER A PERIOD OF 10 YEARS RETROSPECTIVE STUDY

Prof. R. Rajaraman MS., G. Gopu, Dr. S. Deepa., Center for Oncology, Department of Surgical Oncology, Government Royapettah Hospital, Kilpauk Medical College, Chennai.

Introduction Malignant neoplasms of the small bowel are among the rarest types of cancer accounting for only 2 % of all GI cancers. Around 95 % of small bowel tumors are made up of adenocarcinoma, carcinoid tumor, lymphomas and gastrointestinal stromal tumors (GIST). Most small intestine tumors are clinically silent for long periods and present with nonspecific complaints such as intermittent abdominal pain, anemia, bleeding or obstruction. Materials and Methods In this retrospective study spanning over a period of 10 years from 2005 to 2014, we analyzed twelve cases of small bowel neoplasms. Results The study included 8 males (66.7 %) and 4 females (33.3 %). Median age at presentation was 51 years (range 30–77 years). The most common symptoms were abdominal pain (66.7 %), weight loss (50 %), haemetemesis (16.7 %), vomiting (33.3 %). Histopathological diagnosis consisted of lymphoma (33.3 %), adenocarcinoma (33.3 %) and GIST (33.3 %). Tumor was located in jejunum in 7 cases (58.3 %), duodenum 3 cases (25 %), and ileum 2 cases (16.7 %). Resectability rate was 83.3 % and 2 cases were treated with chemotherapy. Five years survival rate of 9 patients was 33.3 %. Conclusion Small bowel tumors with its rarity and varied presentation pose diagnostic challenges. Adenocarcinoma histology and duodenal site have dismal prognosis.

ER 082

Primary Carcinosarcoma of the gall bladder

1. Dr Channabasappa kori, Sameer Gupta, Vijay kumar, Senior resident Dept of surgical oncology, King George medical college, Lucknow

Abstract: Carcinosarcoma of the gall bladder (CSGB) is an extremely rare condition accounting for less than 1 % of malignant gall bladder tumors. Exact aetiopathogenesis is not known and often an incidental diagnosis. Prognosis of CSGB remains poor despite curative resection as compared to gall bladder carcinoma (GBC). Histological hallmark of CSGB is presence of both carcinomatous and sarcomatoid element. Surgery is the best treatment modality for CSGB with dismal role of chemoradiotherapy. Based on extensive literature review, about 80 cases were reported and the tumor size of CSGB ranging from 2.5 to 16 cm. Here, we describe a rare case of CSGB with largest tumor size measuring 35 × 25 cm in a 50 years old lady and is the largest tumor size reported in the literature till date. The present case emphasizes the need for better detection and thorough evaluation of such rare entities, to identify their clinical course and effective treatment methods. Key words: carcinosarcoma, gall bladder, liver

ER 083

Prospective randomized study comparing Robotic-assisted surgery with laparotomy for rectal cancer in India - Follow up data

Dr. Prasanna G, Dr. Somashekhar SP, Dr. Shabber S Zaveri, Dr. Rajshekhar Jaka, Dr. Monika Pansari, Dr. Rohit kumar

Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore

Aim: Rectal cancer is one of the common cancers in India. Open rectal surgery is considered the gold standard treatment for rectal cancer. The aim of this study is to evaluate the safety, feasibility, technique and outcomes (oncological and functional) of robotic rectal surgery in comparison with open surgery in the Indian population. Materials and methods: A prospective randomized study was undertaken from April 2011 to March 2013. Ninety patients who presented with rectal carcinoma were randomized to either robotic arm (RA) or open arm (OA). Both groups were matched for clinical stage and operation type. Three years follow up data presented. Results: The mean operative time was significantly longer in the RA than in the OA (310 vs. 246 min, P < 0.001). The mean estimated blood loss was significantly less with RA compared to OA (165.14 ml vs. 406.04 ml, P < 0.001). None of the patients had margin positivity. The mean distal resection margin was significantly longer in the RA than OA (3.6 vs. 2.4 cm, P < 0.001). Conversion rate was nil. The mean hospital stay was significantly shorter in RA (7.52 vs. 13.24 days, P < 0.001). Post-operative and functional outcomes (urinary function, erectile dysfunction & retrograde ejaculation) were comparable between the two groups. Only one patient had recurrence in robotic arm at 22 months and underwent APR. Conclusion: In comparison to open method, it has advantages of decreased blood loss, less postoperative complication and shorter length of hospital stay. Morbidly obese patients are more suitable for robotic assisted approach. We conclude that robotic assisted rectal cancer surgery is safe with low conversion rates, acceptable morbidity and is oncologically feasible.

ER 084

ASSESMENT OF PATHOLOGICAL RESPONSE AFTER NEOADJUVANT THERAPY FOR OESOPHAGEAL AND OESOPHAGO-GASTRIC JUNCTION CARCINOMA – A SINGLE INSTITUTION EXPERIENCE.

Kiran Gulabrao Bagul, Sudheer O V, Dinesh, Pavithran, Amrita Institute of Medical sciences, Ponekkara P.O. Kochi, Kerala. 8086052279. Email: kirangb@aims.amrita.edu

Aim- To assess the incidence of pathological response after neoadjuvant therapy (NAT) in esophageal and gastro-esophageal junction (OG) carcinoma. To analyse correlation between pathological response and the Overall Survival (OS) and recurrence. Method- From January 2005 through December 2012, all patients with carcinoma esophagus and OG junction from a single institution receiving neoadjuvant chemo- radiotherapy/chemotherapy alone followed by esophago-gastrectomy were reviewed retrospectively for pathological response by Mandard Tumor Regression Grading system (TRG). Therapy related mortality, morbidity, long-term survival, and factors affecting survival also analysed. Result-total 58 patients received NAT. Twenty (34.4 %) patients showed complete pathological response (TRG-1). Majority of the patients with TRG-1 were esophageal carcinomas (18 out of 20) whereas majority of OG junction tumors show incomplete response (TRG-2 to 5). Median follow up period was 30 months. Two (3.4 %) patients died due to chemo-radiation induced toxicity, and 4(6.8 %) patients died of postoperative complication. Median OS of entire population was 25 months. With a Disease free interval (DFI) of 14 months, 20(34.4 %) patient show recurrence. Only 3 patients in TRG-1 group recurred as compared to 17 patients with incomplete pathological response (TRG2-5) group. Median OS of patients with TRG-1 was 32.8 months. Median OS of patients with incomplete pathological response (TRG-2-5) was 26 months. Conclusion- Complete pathological response (TRG-1) can be achieved with neoadjuvant therapy. This response is more in esophageal carcinoma than OG junction cancers. Complete pathological response reflects less incidence of recurrence and improved overall survival. The analysis of determinants of complete responses should be the goal of future research.

ER 085

Intersphincteric resection and hand sewn colo-anal anastomosis for low rectal cancer – Short term outcomes in the Indian Setting

Vishwas Pai, Ashwin Desouza, Suprita Arya, Prachi Patil, Reena Engineer, A P Saklani, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India- 400012

Introduction: The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with Magnetic Resonance Imaging (MRI), has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario. Material and methods: All patients with low rectal cancer who underwent an intersphincteric resection at the Tata Memorial Centre from July to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin(CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and circumferential resection margins) and lymph node yield. Short term perioperative outcomes included 30 day mortality, postoperative morbidity, anastomotic leaks and length of hospital stay. Results: Thirty three patients with low rectal cancer and a median age of 38 years underwent intersphincteric resection during the defined study period. Twenty three patients (70 %) underwent open surgery whereas 10 patients received a laparoscopic resection. The median blood loss and hospital stay was 300 ml and 7 days respectively. Two patients had an involved CRM, but all distal margins were free of tumour. .. The quality of Total Mesorectal Excision (TME) was satisfactory in all patients with a median lymph node yield of 9 nodes. Conclusions: Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

ER 086

Neoadjuvant chemotherapy in locally advanced gastric cancer with Epirubicin, Oxaliplatin, capecitabine [EOX] and Capecitabine and oxailiplatin[XELOX] regimens: A retrospective analysis

Suhaildeen K, Ramakrishnan A S, Department of Surgical oncology, Cancer Institute(WIA), No. 18, Sardar Patel road, Guindy, Chennai - 600 036

Background: Gastric cancer is one of the leading causes of cancer deaths. To improve treatment outcomes multimodality therapy has been commonly used. Here, we report on the use of the EOX and XELOX regimen in the neoadjuvant setting in patients with locally advanced carcinoma stomach. Method: Patients with locally advanced adenocarcinoma of the stomach and the gastro-oesophageal junction between Aug 2010 and Jan 2014 who received neoadjuvant chemotherapy were analysed. Forty-one patients (median age: 52, range 24–72 years) with locally advanced adenocarcinoma of the upper GI-tract received up-to 3 courses of Neoadjuvant chemotherapy with EOX or XELOX. Five patients had potentially operable disease and 36 patients had borderline/ potentially inoperable disease on CT Scan. Post neo-adjuvant treatment response was assessed and patients underwent surgery followed by adjuvant chemotherapy. Results: 40 patients completed all three planned cycles of neoadjuvantchemotherapy, 1 patient received only two cycles and defaulted. Of the 36 patients considered initially inoperable 17 underwent surgery with R0 resection [47 %] with 4 pathological complete response [pCR]. Five patients had progression on CT scan and 10 patients were found to be inoperable at surgery. Of 5 patients with potentially operable disease 3 underwent surgery with R0 resection, 2 were inoperable due to peritoneal disease. Only 3 patients experienced toxicities including 1 grade III Thrombocytopenia, 1 grade I myelosuppresion, 1 grade II diarrhea. Conclusions: We conclude that EOX and XELOX is a well-tolerated and efficacious as neo-adjuvant treatment in patients with locally advanced adenocarcinoma of the upper GI-tract. The high efficacy in terms of R0 resection rate and pCR is very promising. Keywords: Locally advanced gastric cancer, neoadjuvant chemotherapy, Oxaliplatin, Epirubicin, Capecitabine

ER 087

The impact of optic nerve resection length on survival in Retinoblastoma

Type

EITHER

Caleb Harris ^{a, 1}, Sajid Qureshi ^{a, 2}, Monica Bhagat ^{a, 1}, Girish Chinnaswamy ^{b, 2}, Mukta Ramadwar ^c,2, Nandan Shetye ^{d, 2}

¹Senior Resident, ²Consulatant;^a Department of Surgical Oncology, ^bDepartment of Medical Oncology, ^cDepartment Pathology, ^dOphthalmologist, Tata Memorial Centre, MuMbai

Address: Department of Surgecal Oncology, Tata Memorial Hospital, Parel, Mumbai-400012

Email: calebhar@gmail.com; Phone: 91 22 24177000, 919969375606

Aim Enucleation cures most patients with uniocular retinoblastoma, however, some patients presnt with extraocular relapse after enucleation. This study was done to determine if the resection length of the optic nerve had an impact on the survival so as to guide surgeons to do optimum surgery and thereby improve outcomes. Methods This was a retrospective analysis of prospectively maintained data at our tertiary centre. Institutional Ethics Committee permission was obtained for the study. No funding was received. All patients who had undergone surgery for Retinoblastoma between September 2004 and September 2013, were included. Univariate and multivariate analysis was done and Kaplan Meiyer curves plotted. Results A total of 115 cases were included in this study. The median length of optic nerve obtained was 1 cm (range 0.2–2.5 cm). Of the 18 cases wherein there was involvement of the optic nerve, the cut margin was found to be positive in only one case. Histological factors were unfavorable in 44 patients, no residual tumor in two and rest favorable. The event free survival was better in patients with optic nerve length >1 cm than in patients with optic nerve length <1 cm (p < 0.03). Conclusion Better event free survival is seen with 1 cm or more of resected optic nerve length. Thus optimal surgery should include at least 1 cm of tumor free length of optic nerve to improve outcomes. Through we could arrive at a cutoff value of 1 cm of resected optic nerve length, further studies are necessary, with more patients, to stratify the resected length as to whether lesser wuld suffice.

PS 088

A CASE OF MONOPHASIC SYNOVIAL SARCOMA OF MANDIBLE: A RARE ENTITY

NK Saidha, Pauline Babu, Command Hospital Air Force, Bangalore

Keywords: synovial sarcoma; mandible; immunohistochemistry Abstract Synovial sarcoma is a common mesenchymal malignancy which represents approximately 10 % of all soft tissue sarcomas. It frequently affects the extremities, and only 8 % of cases have been reported in the head and neck region. It typically occurs in young adults and is more common in males than females. The most common sites in the head and neck region are hypopharynx and parapharyngeal spaces. However, it can also occur in tonsils, tongue, and orofacial soft tissues. Synovial sarcoma involving mandible is extremely rare and only 9 cases have been reported worldwide. The diagnosis of the classic biphasic synovial sarcoma is simple, but the monophasic forms require immunohistochemistry for confirmation. When monophasic variants arise in unusual sites, such as the head and neck region, recognition and differential diagnosis become more difficult. It is important to diagnose this entity in such locations correctly because wide surgical excision without regional node dissection is the mainstay of the management. Because of its rarity in the head and neck region, especially in the jaws, and the risk of misdiagnosis of monophasic variants in unusual sites, the management of synovial sarcoma of mandible requires an integrated multidisciplinary approach. Aim: A rare case of primary monophasic synovial sarcoma of the mandible is presented here, with reference to its clinical, histopathological, and immunohistochemical features, and the subsequent management.

PS 089

Juxtathyroidal neck soft tissue angiosarcoma presenting as a neck nodule in case of Hoshimoto’s thyroiditis, a case report.

Abhinav Pandey, Vivekanand Sharma, Raj Govind Sharma, Surgical Oncology Division, Upgraded Department of Surgery, S.M.S. Medical College and Hospital, Jaipur, Email: drabhinavpandey1987@gmail.com

Aim: To study and discuss a very rare form of soft tissue angiosarcoma of neck in case of Hashimoto’s thyroiditis presenting as diagnostic dilemma. Method: We present the case of 55 years old female with long standing thyroiditis and history of nodulectomy 15 years ago who presented with 2 months history of rapidly enlarging 3 cm size mass on right side of neck with bilateral cervical lymphadenopathy. Patient presented to us with three fine needle aspiration cytology reports showing benign epithelial neoplasm to suggestive of poorly differentiated carcinoma, Ewing’s sarcoma and atypical squamous cells respectively. Core needle biopsies were too inconclusive suspecting epithelial tumor. Ultrasonography thyroid and cat scan revealed a separate mass posterior to sternocleidomastoid with thyroiditis in thyroid. With probable primary as thyroid, total thyroidectomy with right sided modified radical neck dissection was done along with excision of neck mass resulting in extirpation of all gross disease. Results: Final pathology and immunohistochemistry reports revealed high grade angiosarcoma neck with Hashimoto’s thyroiditis. Post-surgery patient had uneventful course and no recurrence or metastasis seen on follow up at 1 and 6 months. Conclusion: Our case illustrates that how a rare neck malignancy like angiosarcoma can present as diagnostic dilemma. It should be considered in differential diagnosis of thyroid swellings along with thyroid angiosarcoma.

PS090

PRIMARY INTRA-ABDOMINAL RHABDOMYOSARCOMA IN AN ADULT: AN UNUSUAL PRESENTATION AND REVIEW O F LITERATURE

Sanjay Kumar Yadav^4*,R S Sharma¹, Dipendra Kumar Sinha¹, M D Kerketta², Mimi Sinha³, ¹ Deptt. of General Surgery Rims, Ranchi, Jharkhand(India)- 834009, Email- sky1508@gmail.com

Background- Rhabdomyosarcomas, the commonest soft tissue sarcoma in paediatric age group, represent 5–10 % of all solid tumors in childhood. These tumors are rare in adult population. There are sporadic case reports of intra-abdominal rhabdomyosarcoma, but mostly in paediatric age group. Methods(Case Reprot)- Here we are reporting an unsual case of intra abdominal rhabdomyosarcoma in an elderly which presented with acute intestinal obstruction. Upon emergency exploratory laparotomy a hard mass was found to be compressing the ascending colon and infiltrating into duodenum, pancreas and liver. No specific organ of origin could be identified. Biopsy was taken, as the mass was unresectable and ileostomy was done. Results- Histopthological examination revealed embryonal rhabdomyosarcoma. Conclusions- Due to very rare presentation of this disease, it may be missed. Large multicentric studies are required to establish proper treatment modality.

PS 091

EXTRA SKELETAL MESENCHYMAL CHONDROSARCOMA: A CASE REPORT

Rajaraman, Subbiah Shanmugam, Navin Noushad

Introduction: Chondrosarcoma is the third common malignant primary bone neoplasm. The extra skeletal mesenchymal variant is an aggressive tumor and accounts for less than 1 % of all sarcomas. It is unique among other chondrosarcoma variants in that it affects children and young adults, and in its responsiveness to chemotherapy. This case is presented for its rarity and atypical presentation. Presentation: A 58 years old female presented with painless rapidly progressive swelling of left lower anterior thigh. On examination a 10 × 8 cms mobile, swelling arising from the anterior thigh muscles. Local MRI revealed a heterogeneously enhanching soft tissue lesion involving rectus femoris and vastus lateralis muscles but free from femur. A core needle biopsy was suggestive of malignant spindle cell neoplasm. A provisional diagnosis of soft tissue sarcoma made, and wide excision with adequate margins was done. Post op histopathology confirmed negative margins and a bimorphic tumor composed of small round cells with multiple areas of focal differentiated cartilage formation. A diagnosis of extra skeletal mesenchymal chondrosarcoma was made and patient received post op adjuvant radiotherapy and sequential adriamycin, ifosfamide chemotherapy, and is free from disease on follow up. Conclusion: Mesenchymal chondrosarcoma is a aggressive tumor with characteristic bimorphic histology and responsiveness to chemotherapy. It affects individuals under 40 years and involves the axial skeleton. Among extra skeletal sites extremity somatic tissues predominate. It does not have a unique genetic pattern or a reliable IHC marker. Treatment is surgery with adjuvant therapy. Prognosis is poor compared to other variants and the role of chemotherapy needs clarification .

PS 092

DEVASTATING COMPLICATION OF CUSTOM MEGA PROSTHESIS IN TREATMENT OF GIANT CELL TUMOUR MANAGED WITH KNEE ATHRODESIS.

R. Balaji, P.V. Vijayaraghavan Giriraj M.S., Sri Ramachandra Medical University, porur, chennai-600116.

Aim: MANAGEMENT OF INFECTED CUSTOM MEGA PROSTHESIS IN GCT TREATED WITH KNEE ARTHRODESIS. CASE HISTORY: 28 years young male was diagnosed to have GCT of distal femur with intra-articular extension who underwent excision of tumour and custom mega prosthesis(cmp) fixation done. patient developed discharging sinus with infected CMP in situ. patient underwent multiple debridement with IV antibiotic coverage ended up in arthrodesis with ilizarov fixation. GCT a local aggrresive tumor which often treated with extensive curretage and bone grafting and PMMA augmentation or CMP application with most successive results. which rarely ends up in infection which is hard to manage. which we managed to end up with knee arthrodesis with Ilizarov appartus.

PS 093

Fibromatosis of scapula

Parthiban, Gowtham, Dorai kumar, Mohan Chowdry, Sri Ramachandra university, porur, chennai

Aim: To present a rare case of fibromatosis of scapula. Introduction: Desmoid tumours are rare which account for 0.03 % of all neoplasm and less than 3 % of soft tissue tumour. Desmoid tumour are locally aggressive and high rate of recurrence even after complete resection. Case history: 41 years old male presented with swelling of right scapula and limitation of range of movement since 4 years. Patient underwent CT scan showed lytic lesion with sclerotic margins of scapula with posterolaterl chestwall involvement and biopsy revealed fibromatosis right scapula. Immunohistochemistry positive for beta-catenin and negative for s-100. wide excision of tumour with partial scapulectomy(Type 2 scapula resection) under GA was done. Post operative period was unevetfull and patient being started on shoulder mobilization. Patient clinically improved with range of movement.

PS 094

Reconstruction Arthroplasty of Distal Radius GCT – CASE REPORT

Karthik Neelakandan, E. Pradeep, K. Anbalagan, Department of Orthopaedics, SRM Medical College & RC Kattankulathur, E-mail – dr_nk2001@yahoo.co.in

Giant cell tumour of the distal radius is the most commonly involved site next to distal femur and proximal tibia. Various techniques have been advocated for the management of distal radial GCTs aiming to achieve satisfactory removal of the tumour, lessen the chance of recurrence and preserve as much of wrist function as possible. The treatment consists of either curettage or en-bloc resection of the lesion with subsequent reconstructions. Our case is that of a 25 years old gentleman reporting with complaints of sudden onset pain increasing over left wrist for 15 days. He previously had minimal pain in the wrist while exercising for the past 1 month. Clinical findings revealed tenderness over distal radius with minimal swelling. Range of movement for the left wrist was limited due to pain. A plain radiograph of the wrist revealed an expansile lytic lesion at the distal radius. The cortex was thinned and ballooned with an area of cortical breakthrough in the medial volar aspect of the distal radius. MRI evaluation revealed the same with the extent of lesion demarcated. With these a diagnosis of giant cell tumour Campanacci grade 3 was made and a needle biopsy confirmed the diagnosis of Giant cell tumour. He subsequently underwent a wide excision of distal left radius and autologous ipsilateral proximal fibular grafting. He was assessed on regular intervals with initial immobilisation for a period of 8 weeks and gradual mobilisation. At the recent follow – up of 1 year period union of the graft – bone site had occurred and the patient had good functional outcome as per ISOLS functional grading with flexion of 45 deg and extension of 35 deg and no signs of recurrence. Wide resection and autologous fibular reconstruction provides the choice of enabling the patient with a better functional wrist.

PS 095

Metachronous Osteosarcoma: A Report of 5 cases

Upasana Upadhyay, Mohamed Sameer, Kathiresan. N, Mayilvahanan Natarajan, Resident Medical Officer, MN Orthopaedic Hospital 14, Bank street, Kilpauk, Chennai- 600010 E mail: r.uupadhyay@gmail.com

Background & Methods: Multifocal osteosarcoma is described as occurrence of tumours at two or more sites in a patient without pulmonary metastasis. It may be synchronous (more than one lesion at presentation) or metachronous (new tumours developing after initial treatment). We report 5 cases of metachronous osteosarcoma which we treated over the past decade. All the 5 patients had biopsy proven osteosarcoma and were treated effectively with chemotherapy and resection surgery and replacement with custom prosthesis. All of them had a disease free interval (ranging from 8 months to 4 years), before they developed tumour at another site. Results: One patient denied further treatment and was lost for follow up. Three patients who underwent workup, resection and replacement with Custom prosthesis developed metastasis after appearance of the metachronoustumour (range 8 to 18 months) and died of disease. No recurrence of local tumour or metastasis have occurred in one patient who is currently alive (follow up 8 years from initial diagnoses) and free of disease. Conclusion: Metachronus Osteosarcoma should be recognised as a sequela in survivors of primary Osteosarcoma survivors. Theetiology however, is unknown. Meticulous follow up is required to permit early detection and successful therapeutic intervention.

PS096

Functional outcome and Quality of Life of soft tissue and bone cancer patients who underwent Above Knee Amputation using modular Endoskeletal Prosthesis VS Patients who underwent Redo Limb Salvage surgery.

M.S. Satish¹, Srinivasan Vijay¹ & Dr. N. Kathiresan², Dept of Physiotherapy, Cancer Institute (WIA) Chennai.

Introduction; Soft tissue and bone sarcoma’s are a rare and heterogenous group of tumors, these neoplasms represent less than 1 % of all adult and 15 % of pediatrics malignancies. From an era of only Amputation, medical and technological advancement has enabled to do Limb salvage Surgeries in about 90 % of bone tumors. The incidence of mechanical and biological complications are 17 and 15 % respectively for the patients who underwent Limb Salvage surgery(LSS) using Custom made mega Prosthesis. Current study aims to compare the Quality Of Life (QOL) and functional status among patients with soft tissue and bone tumors of lower limb treated with LSS or who underwent Above knee amputation and rehabilitated with endoskeletal type prosthesis, with 4 bar mechanism knee joint. Methodology; Patients (n = 32; Age ranged between 15 and 60 years) who underwent Redo LSS or Above Knee Amputation rehabilitated with endoskeletal type prosthesis (4 Bar Mechanism Knee joint) who reported to Department of Physiotherapy between May 2013 and April 2014 were assessed for their QOL and Functional Outcome using Cancer Institute QOL Questionnaire and Musculo Skeletal Tumor Society Score(MSTS). Results were analysed using Student ‘t’ test, Descriptive analysis and Chi square test. Results; 56.3 % of the patients had Average QOL, while 34.4 % reported High QOL and Low QOL was reported by 9.4 % of patients. LSS and Amputees found to differ significantly in fear of recurrence (x⁽¹⁾⁼ 11.603, p = 0.009), while 52.9 % of Amputees had no fear of recurrence, 66.6 % of Redo LSS patients had moderate to severe Fear of recurrence. There is a significant difference among amputees and redo LSS in body image (t = 2.504;p value = 0.018),emotional acceptance (t = 3.962;p value = 0.000), support (t = 3.846;p value = 0.001) and MSTS score (t = 3.013;p value = 0.005). Conclusion; Majority of the patients were able to attain average to good Quality of life and functional status, body image was better among redo LSS patients while fear of recurrence was high among majority of redo LSS.

PS097

Necessitate of Shoulder Exercise in Mastectomy Patients Receiving Post Operative Radiotherapy.

Srinivasan Vijay¹, M.S. Satish¹ & V. Sridevi, Dept of Physiotherapy, Cancer Institute(WIA)-Chennai.

Background and Aim: Breast cancer is the most common cancer reported in India. The incidence rate of breast cancer at Cancer Institute in 2007–08 is 23.5 %. In Chennai the Breast cancer has shown a significant raise from 14.3 % in 1982 to 24.4 % in 2004. Advancement in treatment of breast cancer has improved dramatically with the overall 5 years survival rate increased to 80.5 %. It has been reported that shoulder dysfunction is one of the major problem following surgery^. Shoulder Range of Motion (R.O.M) is limited in 86 % of patients who have undergone axillary clearance^. However the Shoulder R.O.M restriction and its influence on treatment initiation and completion of Radiotherapy(RT) in Post mastectomy patients is under reported. Good Shoulder mobility is desirable in Post Mastectomy patients planned for Chest wall Irradiation. Hence we aim to analyse the necessitate of shoulder ROM in post mastectomy patients receiving RT and their Quality of life(QOL). Methodology: Patients(n = 93) attending Physiotherapy OPD from January to December 2012 who underwent mastectomy and planned for RT were assessed for their Shoulder ROM using Goniometer and CI-QOL questionnaire. Data were analysed using SPSS 13 Software. Results: Sixty-six percent of patients had full R.O.M, 21 % patients had end range restriction, 10 % had abduction till 90° only and 3 % had abduction <60°. Majority of the patients had full Mobility of their shoulder joint following regular exercise intervention. 53.1 % had Average QOL, 26.5 % had above Average QOL, 12.2 % had low QOL and 4.1 % had very low QOL. There is a significant relationship between QOL and Shoulder ROM. Conclusion: Majority of the patients had full Mobility of their shoulder joint following regular exercise intervention. While few patients had shoulder restriction their Radiation therapy was completed with certain modifications on board. This study can be followed up with another Study on Non- Adherence to Shoulder exercise and its influence on Post mastectomy Radiation therapy treatment completion and complications.

PS 098

UNUSUAL POSTERIOR MEDIASTINAL CYST

Santosh K Ijeri, Sandeep Nayak, Srinivas, M. Vijaykumar, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, DR M H Marigouda road, Bangalore- 560029. Karnataka, India, Mail id- dr.santuijeri@gmail.com

Aim: To discuss unusual case of mediastinal cystic lesion and its management. Methods: A 65 years male patient presented with difficulty in breathing and change in voice. On investigation found to have a mediastinal cystic lesion for which Right lateral thoracotomy with cyst wall decompression and marsupilisation was done. Results: Histopathology of the cyst wall showed tumor cells arranged in papillary pattern comprising of low columnar cells - papillary carcinoma. Total thyroidectomy was done and histology showed papillary carcinoma thyroid. Conclusion: Carcinoma thyroid can present as unusual mediastinal cyst which can cause diagnostic dilemma especially if primary lesion is occult.

PSS 099

Adenoid cystic carcinoma of the nasal septum-rare location for a common tumor

Prem Nivas, K. Senthil, Head & Neck Surgery, Sri Ramachandra University, Chennai

Abstract: Adenoid cystic carcinoma(ACC) is a malignant tumour frequently described as arising from seromucinous salivary tissue in the major and minor salivary glands. Within the nasal cavity, it is uncommon and usually involves the lateral wall. Its occurrence in the nasal septum is very rare. We present a case of a 42 years male patient who presented with repeated episodes of epistaxis over a period of 2 years. Anterior rhinoscopy showed a well circumscribed mass arising from the septum. Endoscopc excision of the mass under general anesthesia was done. Histopathology showed cribriform pattern of adenoid cystic carcinoma with clear margins and no perineural spread. Hence, no further adjuvant therapy in the form of radiotherapy was warranted for the patient. Adenoid cystic carcinomas are slow growing tumors, which are amenable to surgical management. ACC has a high incidence of local recurrence and distant metastasis rate; therefore, long-term follow-up is necessary.

PS 100

An Algorithm For Reconstructing Large Lower Lip Defects Encountered In Ablative Cancer Surgeries

Rinku George, Arvind Krishnamurthy, Department of Surgical Oncology, Cancer Institute, S.P. Road, Adyar, Chenia 600020, Email ID- rinkugeorge@gmail.com

Aim- Large defects of the lip are always a technical challenge for the reconstructive surgeon. The aim of this study was to analyze the techniques used in reconstructing various full thickness lower lip defects with free flaps. Methods – Three patients, one with a total lower lip loss with full thickness defect involving both mucosa and skin, another with total lower lip loss involving only the vermilion region with no skin defect, and another patient with full thickness loss of one half of the lower lip loss along with a segmental defect of mandible was reconstructed with free flaps and was followed up for 6 months. The Flaps used were Radial forearm, and Fibula. Results – All the flaps healed well with acceptable function and esthetics. The patients were able to speak clearly, and eat food without drooling after 6 months. Conclusion – Free flaps are an excellent solution to reconstruct large full thickness lip defects. Although many flaps are available, the two flaps, the radial forearm and fibula can be used to reconstruct both total lip defects and composite defects which involve the lip. Presented here is a simple algorithm for lip reconstructing lower lip defects with free flaps.

PS 101

AUTO PENECTOMY DUE TO PENILE CARCINOMA

Jitin Yadav^1*, R.G. Baxla², M. Mundu³, C.P. Sinha³, R. C. Besra⁴, Satish Kumar¹, OM Prakash¹, Sumegha Rana^1, Department of General Surgery, Rajendra Institute of Medical Sciences, Ranchi-834009

Email-jitindrcool@gmail.com

Introduction- Incidence of penile carcinoma is decreasing worldwide. Nevertheless, the incidence of penile cancer is still significant in various tropical countries, and it often presents in advanced stage. We report two unique cases of penile auto-amputation due to advanced cancer. Methods-CASE REPORT:-A 55 years old male presented with foul smelling ulcerative lesion replacing penile base following automatic sloughing of the whole penis and voiding dysfunction. Biopsy of the base of the penis confirmed penile carcinoma. In addition, the patient had metastatic inguinal lymph nodes. Supra-pubic cystostomy was the initial management followed by combined chemo-radiation, but he lost to follow up. Results-HPE result was suggestive of well differentiated, squamous cell carcinoma. Conclusion- Emphasis must be placed on early diagnosis and treatment of penile cancer, so further development of the disease can be prevented.

PS 102

Primary Urachal carcinoma- a rare case report and review ofliterature

Dr. Kailash Ramrao Surnare, Dr. Nithin leekha, Dr. Paul Augustine, Dr. Kurian Cherian, Dr. Iqbal Ahamed M, Division of surgical oncology, Regional Cancer Centre (RCC), Medical College Campus, Trivandrum -695011, E mail: kailashsurnare@gmail.com

Introduction: Primary urachal adenocarcinoma is an aggressive rare cancer that often presents at an advanced stage with poor prognosis. In this case report we have discussed clinical presentation, radiologic, histologic properties, treatment approach of urachal cancer in a young man with accompanying literature. The reported 5-year survival rates are 27 to 61 % for urachal cancer. Presentation of Case: A 45-year-old male was evaluated for dysuria and hematuria for 2 months duration. On clinical examination a soft mass was palpable in hypogastric region with blood stained pus discharge from the umbilicus. Computerized tomography of abdomen and pelvis revealed a mass lesion in the patent urachus extending to the urinary bladderdome. Cystoscopy guided bladder dome mass biopsy was negative for malignancy. The tumor was removed by wide excision of tumor with partial cystectomy. Histopathological examination showed urachal adenocarcinoma (moderately differentiated mucinous adenocarcinoma), which had invaded the urinary bladder. The margin of resection was free of tumor with 1 cm clearance. No adjuvant treatment was given. The patient is doing well at 6 months follow up. Discussion: Adenocarcinoma is rare form of bladder tumor of which primary urachal carcinoma is still rarer and account for less than 0.5 % of all bladder malignancies. Adequate surgery for urachal carcinoma is debatable but a margin free resection seems to be adequate, are crucial to long-term survival. Patients can be treated with either partial orradical cystectomy to achieve negative margin. Conclusion: Urachal carcinoma is an aggressive rare tumor of bladder. Surgeryresection with adequate margin forms the main stay of treatment. The role of adjuvant chemotherapy or radiation therapy not well defined.

PS103

Metastatic Renal Hemangiopericytoma: A rare case report

Ramana Reddy Naru, Narendra H, Amitabh Jena, Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupathi, Andhra Pradesh- 517507

Introduction: Hemangiopericytoma (HPC) is an unusual perivascular tumor and first case was described by Stout and Murray in 1942. Moreover, it is classified as a soft-tissue vascular tumor originating from pericytes, which occurs commonly in the extremities, pelvis, head and neck, meninges and rarely encountered in urogenital system. Renal HPC is also extremely rare tumor and only 41 case reports have been previously documented. Herein, we described a case of HPC of the left kidney with lung metastasis. Case Description: A 56 years old female came with complaint of lump and pain abdomen since 1 month. Clinically we thought renal cell carcinoma. CECT Abdomen &chest suggestive of Large well defined lobulated heterogenously enhancing soft tissue density lesion measuring 14 × 8 cm noted arising from the lower pole of kidney with central calcification and few Nodular opacities noted in both Lungs largest in right lower lobe measures 1.8 × 1.8 cm (RCC left kidney with lung mets). The right radical nephrectomy was performed. The histopathological evaluation confirmed haemangiopericytoma by immunohistochemistry. The patient recovered well and planning for adjuvant therapy. Discussion: HPC is an uncommon soft-tissue vascular tumor that occurs due to the uncontrolled proliferation of pericytes, which are cells spiraling around capillaries. There are no specific signs or symptoms. The mean age of the renal HPC patients at the time of initial diagnosis is 40.3 years. No specific findings of renal HPC have been found on USG, CT scan or MRI that might aid in the differential diagnosis with the other renal tumors. The complete surgical excision was considered to be the cornerstone in first treatment of renal HPC.

PS104

Oncocytic tumor of the adrenal cortex-a rare entity

Durga CK, Naskar D, Sharma D, Agarwal H

Aim: To review the presentation and diagnostic examination of adrenocortical oncocytoma Method: Case report from a tertiary care hospital (Dr. RML Hospital) of a 45 years old male who presented with a large intrabdominal lump 15*18 cm in size involving epigastric, left lumbar, left hypochondrium and umbilical region. Patient’s CECT abdomen was suggestive of left sided RCC with no invasion of blood vessels. Result: After preoperative evaluation and workup exploratory laporotomy with left side nephrectomy and splenectomy was done. Patient was discharged on 11th day in good condition after vaccination. Final histopathological report showed it to be oncocytic tumor of adrenal cortex origin. Conclusions: Oncocytes are tumor cells that are highly eosinophilic and granular due to prescence of large number of mitochondria. Oncocytomas are mostly located in kidney, thyroid, pararthyroid and salivary glands and are usually benign. Adrenal cortex oncocytomas are rare tumors (only 147 cases reported so far). They are more prevalent in women and more on left side. They are usually benign tumors and nonfunctioning. A few of the cases may present as functioning tumors hence biochemical analysis is important. They most frequently present as large intrabdominal mass. However, there is dilemma regarding its preoperative diagnosis as there is no characteristic CT or MRI finding. Histopathological examination can only provide definite diagnosis in these cases. They are strongly positive for vimentin, alpha-inhibin and melan A. They are well circumscribed and encapsulated and on cut section are yellow to tan brown in colour. Lin-Weiss-Bisceglia system is used to determine its malignant potential. Since they present as large mass surgical excision is mostly required. Smaller tumors can be dealt laporoscopically while large ones requires open approach. Role of other modalities (chemotherapy and radiotherapy) has not been studied well till date.

PS105

HEPATOCELLULAR CARCINOMA WITH CUTANEOUS METASTASIS TO BACK :

Sanghamitra Jena, Sarbajit Das, Indranil Das, Department of Surgical Oncology, Saroj Gupta Cancer Centre and Research Institute, MG Road, Thakurpukur, Kolkata-700063

Email: docsalu@gmail.com

Abstract Hepatocellular carcinoma (HCC) is the most common primary tumour of the liver. It mostly metastasise to lungs, followed by abdominal lymph nodes and bones. However, cutaneous metastases of HCC are very rare, accounting for 0.2 to 2.7 % of all cutaneous metastases. The most common location is the head (usually the face), followed by the chest, the abdomen, and the limbs, but metastasis to back is very uncommon. Herein, we report a case of hepatocellular carcinoma with a cutaneous swelling in the back which on investigation was found to be metastasis from HCC.

PS106

SURGICAL SITE INFECTION AFTER COLORECTAL CANCER SURGERIES – AN AUDIT

Vishwas Pai, Harish Verma, Ashwin Desouza, A P Saklani., Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India- 400012.

Aims and Objectives Surgical site infection (SSI) is the most common cause of morbidity after colorectal surgery. The aim of this study was to assess the prevalence of SSI following colorectal cancer surgeries, to identify risk factors contributing to these SSI and suggest measures for control. Materials and Methods A multicentre observational study of 88 colorectal surgeries performed at Tata memorial hospital(TMH) and Advanced centre for research and education in cancer (ACTREC) over a period of 2 months was performed. A combination of amoxycillin-clavulanic acid with metronidazole was selected as the perioperative antibiotic of choice. Southampton criteria to assess severity or suspicion of infection was used. Results Of 88 patients 37.5 % cases were identified to have SSI with 21.4 % having significant (grade 3,4,5) SSI as per Southampton criteria. All grade 5 infections were associated with anastamotic leak or perforation. Seventy-one percent of diabetics developed SSI as compared to those without comorbidities. Incidence of SSI in perineal wound in both post irradiated patients and in upfront surgery patients was 100 %. Incidence of significant SSI (grade 3,4,5) in laparoscopically assisted surgeries and open surgeries was 3/21(14 %) and 9/67(14 %). Incidence of SSI increased with increase in duration of surgery from 7.6 %(1 h) to 56 %(4 h). Most surgeries performed come under clean-contaminated category 84/88 (95.45 %). Microrganisms were isolated in 17/19 patients with grade 3,4,5 SSI, with E.coli being the most common isolated organism in 9 cases and other gram negative organisms in most other wounds. Hospital stay ranged from 5.4 days in grade 1 to 21 days in grade 5 infections. Conclusion. Incidence of SSI in colorectal surgeries in our setting appears comparable with standard data elsewhere i.e. 23–30 % incidence. Amoxycillin-clavulenic acid and metronidazole appears to be an effective combination in our setting to prevent SSI.

PS 107

ACCURACY OF CLINICO-RADIOLOGICAL METHODS IN DIAGNOSING AXILLARY LYMPHNODE METASTASIS IN CARCINOMA BREAST: A TATA MEDICAL CENTRE EXPERIENCE

Choraria A¹, Agarwal S¹, Sen S², Chandra A², Charkrabarty N², Sinha S³, Ahmed R¹

¹Department of Breast Surgery, Tata Medical Centre, Kolkata, India

Aims: To correlate clinical and radiological sensitivity and specificity with pathological findings in involvement of axillary nodes in case of carcinoma breast. Materials and Methods: A consecutive series of breast carcinoma patients having upfront surgery were included. Prospectively collected data was analysed. Patients having Neoadjuvant Chemotherapy were excluded. Initial clinical examination was recorded on Electronic Medical Records. Routine mammography with ultrasonography was performed as part of triple assessment, to evaluate both breast lesions and axilla. Ultrasonographic characteristics of metastatic nodes were increased size, rounded shape, cortical thickening and loss of hilar character. Clinical and radiological evaluation before surgery was correlated with pathological evaluation of nodal status after surgery. Results: 179 patients meeting criteria were included in this study, of whom 94 (52 %) had pathologically positive lymph nodes. Clinically, 44 (24.5 %) patients were correctly diagnosed with positive and 62 (34.6 %) with negative axillary lymph nodes. There were 50 (27.9 %) false negative and 23 (12.8 %) false positive clinical evaluations. Sensitivity and specificity of clinical evaluation is 46 % and 73 % respectively. By ultrasonography, 56 (31.28 %) patients were correctly diagnosed as positive and 70 (39.1 %) as negative axillary lymph nodes. There were 38 (21.22 %) false negative and 15 (8.37 %) false positive results. Sensitivity and specificity of radiological evaluation by ultrasonography is 60 % and 82 % respectively. Combined clinical and radiological evaluation, with both modalities suggesting metastases, had a Positive Predictive Value of 84 %. However the Negative Predictive Value was much lower at 57 %, giving an Accuracy of 64 % only. Conclusions: Even taken together, clinical and radiological assessment of axillary lymph nodes remains inaccurate, resulting in many patients having unnecessary axillary lymph node dissection. Additional techniques such as elastography may be evaluated to improve radiological evaluation, and wider adoption of Sentinel Lymph Node Biopsy is needed to avoid unnecessary morbidity in patients with negative axillary lymphnodes.

P S108

INTESTINAL METASTASIS FROM PRIMARY BREAST CANCER –REPORT OF TWO CASES

*Arulraj P, **Radha, ***Rajkumar A, *Head, Department of Surgical Oncology, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India- 641 037, E-mail – drarulp@gmail.com.

Introduction: Metastatic cancer involving the intestinal mucosa is relatively uncommon, Between 1988 and 2005, only 36 cases reported (Idelevich et al.), Most common primary cancer were lobular breast carcinoma (47 %), lung cancer (11 %) and malignant melanoma (8 %). Case 1: 50 years old post menopausal lady, Clinical stage –locally advanced breast carcinoma (T4 b N1 M0), Tumor board - in view of fungation –surgery followed by adjuvant therapy, Underwent right modified radical mastectomy. HPE: Pleomorphic lobular carcinoma with infiltration of overlying skin, 6/25 positive nodes (p T4b N2a) IHC: negative for ER, PR and HER2 neu (triple negative). She defaulted from adjuvant treatment, 4 months later presented with C/O acute intestinal obstruction, CECT of abdomen - 4 × 3 cm hypodense lesion in the proximal small bowel with obstruction, Laparotomy –growth involving the mesenteric border of the mid- jejunum with obstruction, Underwent resection and anastomosis. HPE – lesion & 11 mesenteric nodes showed tumor deposits. IHC- Negative for ER, PR, chromogranin, synaptophysin and cytokeratin 20, Positive for CKT & focally positive for GCDFP, In view of metastatic disease, planned for palliative chemotherapy. Case 2: 41 years old female, Clinical stage - T2 N1 MO and planned for surgery, She underwent modified radical mastectomy, HPE: Infiltrating ductal carcinoma (NOS type), 1/22 nodes(p T2 N1a), IHC: Negative for ER, PR, Her 2 neu (triple negative). She completed adjuvant chemotherapy, 5 months later presented with features of intestinal obstruction CECT abdomen - Caecal mass with obstruction & multiple liver secondaries. Metastatic workup- brain & lung metastasis. In view of obstruction underwent palliative right hemicolectomy. HPE &IHC: poorly differentiated carcinoma probably metastatic deposit from breast carcinoma and all 33 mesenteric nodes showed metastatic deposit. Invasive lobular carcinoma: Metastasize to the pia mater, peritoneal surface, retroperitoneum and the gastrointestinal and reproductive organs, Ipsilateral multifocal & bilateral cancers are frequently observed, Negative characteristics of PR, ER, HER-2 neu receptors as well as P53 and EGFR. Conclusion: Although small bowel metastases from primary cancer outside the abdomen is relatively uncommon, these cases reinforced the fact that it is necessary to consider the possibility of metastasis when diagnosing gastrointestinal diseases, and that there is potential for gastrointestinal metastasis in invasive lobular carcinoma.

PS109

Primary Neuroendocrine Carcinoma of Breast: A Case Report

Dr. Vivek Kumar Malhotra, Arnab Gupta,Shravasti Roy, Department of Surgical Oncology, Saroj Gupta Cancer Centre and Research Institute, Thakurpukur, Kolkata E-mail: vivek9537@gmail.com

Abstract: Primary neuroendocrine tumor of the breast is rare; accounting for less than 0.1 % of all breast cancer and less than 1 % of all neuroendocrine tumors.[1] Only 30 cases have been reported in English literature till 2010.[2] We report the case of a 60-year-old female with primary Neuroendocrine carcinoma of the breast with its clinical, radiological, histopathologic and immunohistochemical findings. Immunohistochemical examination is essential for confirmation of diagnosis of neuroendocrine tumor. Introduction: Focal Neuroendocrine differentiation can be found in different histological type of Breast carcinoma including in situ and invasive lobular, colloid or papillary breast cancer. However, the term neuroendocrine carcinoma is applied when more than 50 % of tumor shows such differentiation according to WHO.[4,5] These tumors are usually seen in 6th or 7th decades of life. Morphologic features of primary neuroendocrine tumor of the breast are similar to those of neuroendocrine tumors of lung and gastrointestinal tract. Importantly, the diagnosis can be performed if nonmammary sites are excluded.[5] Immunohistochemical examination showing expression of Chromogranin or Synaptophysin confirms the diagnosis.[6] Case report: A 60 years old post menopausal woman presented with complaint of the lump in left breast for last 6 months. Physical examination revealed a 3 × 2 cm hard lump in upper inner quadrant of her left breast. It was free from skin and deeper structure. Axillary and supraclavicular lymph nodes were not palpable. Mammograhy showed microcalcification. Fine needle aspiration cytology (FNAC) from lump was suggestive of ductal carcinoma. X-ray chest and USG abdomen were done to rule out metastasis. The patient refused breast conservative surgery and underwent modified radical mastectomy. Histopathological report showed moderately large monomorphic cells arranged in solid nests with finely granular chromatin and eosinohilic cytoplasm and scanty ductal differentiation. [Fig 1] These features were suggestive of neuroendocrine carcinoma. Immunohistochemical staining revealed diffuse cytoplasmic positivity for Chromogranin, Synaptophysin and neuron specific enolase [fig 2] which confirm the neuroendocrine nature of the tumor. The tumor cells were strongly positive for estrogen and progesterone receptors. [Fig 3] To exclude a nonmammary primary site, we examined the head and neck, chest, abdomen and pelvis with CT but found no other abnormalities. The diagnosis was primary neuroendocrine carcinoma of left breast. The patient received 6 cycle of Epirubicin based adjuvant chemotherapy and radiotherapy and is currently on hormonal therapy (Tamoxifen).

PS110

METASTASES TO THE BREAST- A RARE ENTITY

Satish Kumar^1*, R. G. Baxla², M. Sarawagi³, M. Mundu⁴, C.P. Sinha⁴, R. C. Besra⁵, B.M. Baski⁵, Sunegha Rana¹, Department of general Surgery, Rajendra Institute of medical Sciences, Ranchi-834009

Background- Metastases to the breast from non-mammary primary tumours are uncommon and account for 0.5–2.0 % of all breast malignancies. Metastatic lesions are much more likely to be multiple or bilateral than primary cancers. If present, typically indicate widely disseminated disease. They tend to be found in the subcutaneous fat, whereas primary breast cancers develop in glandular tissue. The main problem Is differential diagnosis from primary breast carcinoma. Methods- Case report Result- It was the case of ovarian cancer with metastases to the breast. Conclusion- Breast cancer is one of the most common primary malignancies in women, yet metastatic tumors to the breast are infrequent. However, hematogenous metastasis from extramammary malignancies has been reported. In contrast to primary breast tumors, metastasis to the breast generally consists of firm, well-circumscribed, multinodular masses. In addition, the masses are usually superficial and less fixed to surrounding tissues, with the overlying skin generally of normal consistency. Radiographically, mammographic evaluation can provide additional information. Extramammary tumors should be distinguished from primary breast tumors to avoid any unnecessary surgical procedures. Correct diagnosis is vital: surgical interventions for patients with secondary breast cancers are potentially both diagnostic and palliative.

PS111

Quality of life and distress among mastectomized breast cancer survivors

Ms. Michelle Normen, Shameem Varikkodan, C.S. Mani, Psycho-oncology, Madras Cancer Care Foundation, Kumaran Hospital, #214, EVR Periyar Salai, Poonamalee High Road, Kilpauk,, Chennai – 600010, E-mail id-michellen16@gmail.com

Aim To assess the quality of life and distress among breast cancer survivors after mastectomy. Methods Cross- sectional study design with convenience sampling was used. A selected cohort of breast cancer survivors (n = 35) who were disease free for a minimum of 6 months were included. These patients were self-administered the EORTC-QLQ-C30 and NCCN Distress Thermometer. The data was analysed using descriptive and inferential statistics. Results Analysis of the data revealed 54.3 % (n = 19) of the survivors had lymphedema and 80 % reported not undertaking any treatment for this problem. On the EORTC QOL C30 a high global health status/ overall quality of life was found with an average score of 65.95 (SD = 25.83) despite the majority reporting the problem of lymphedema. The average score on the Functional scale was 78.78 (SD = 17.45) on areas such as physical, role, emotional, cognitive and social functioning that were found to be healthy. The Symptom scale showed an average score of 17.56 (SD = 11.27) which indicated a low level of symptoms/problems. The results also suggested that there was no significant relationship between Lymphedema and overall quality of life in this population with regard to the Functional scale (r = −1.35, p > 0.05), Symptom scale (r = −0.07, p > 0.05) or Global quality of life (r = −0.06, p > 0.05). Also there was no significant relationship between year of survival and quality of life (r = 0.36, p > 0.05). Sixty percent of these breast cancer survivors reported no distress to Mild distress whereas 40 % reported Moderate to Severe levels of distress. Conclusion Disease free breast cancer patients reported good overall quality of life. There was no relationship between quality of life and number of years of survival. Majority of the survivors reported having Mild levels of distress.

PS112

Feasibility and efficacy of reverse axillary mapping in identifying arm lymphatics in axilla in patients with early stage breast cancer.

Balasubramanian venkitaraman, Sridevi, Sivram ganesamoni, Email: balapsgimsr@gmail.com, 9444547541

Aim: To evaluate the feasibility and efficacy of reverse axillary mapping(RAM) using blue dye in identifying arm lymphatics in the axilla in patients with early stage breast carcinoma and to evaluate the degree of pathological involvement of arm lymphatics by breast carcinoma. Methods: Prospective study with enrolement of patients with early stage breast cancer (T1,T2,N0,N1), consenting to be a part of the study, being evaluated and treated at the breast oncology department, at cancerinstitue (WIA), Chennai. All subjects were subjected to injection of methylene blue (intradermal and subcutaneous, total 1 ml), injected into the medial aspect of arm, under anaesthesia, lymphatics and lymphnodes taking up blue dye identified in the axilla, dissected out during axillary nodal dissection and sent separately for pathological assessment. Results. Eighteen patients with early stage breast cancer, underwent RAM, blue lymphatics were identified in 14/18 patients, blue lymphnodes were identified in 12/18 patients. Mean lymph node yield from axillary dissection was 17.94 (11–32 nodes) and blue lymph node yield was 1.75 nodes. Nodal staging postoperatively was N0 in 13 patients, N1 in 2 patients and N3 in three patients (possible N3 axillary was suspected in all the three cases intraoperatively). Pathological involvement of the axillary lymphatics was seen in only one patient (patient with N3 axilla). In all the other 11 patients in whom axillary lymphatics could be identified, were found to be free of metastatic disease. Conclusion. Because of the low possibility of metastatic spread of carcinoma breast to arm lymphatics in early stage breast cancer patients, identifying arm lymphatics by RAM could enable in preservation lymphatic drainage of arm and thus possibly decrease the incidence of upper limb lymphedema in breast cancer patients.

PS113

Quality-of-life outcomes after oncoplastic breast-conserving surgery

Ashutosh Chauhan, Mala Mathur Sharma, KP Seshadri, Malignant Disease Treatment Center, Command Hospital(CC), Lucknow, Email: bolubonkey@rediffmail.com

Aim To assess the impact of oncoplastic breast surgery on quality of life cancer patients undergoing breast-conserving treatment. Methods Patients with primary breast cancer planned to be treated with oncoplasty breast surgery were assessed with regard to quality-of-life and self-esteem outcomes preoperatively and 6 and 12 months postoperatively. Another set of breast cancer patients treated previously by conventional breast conservative surgery in previous 2 years previously, were assessed as the control group. Validated questionnaires (Short Form-36 and the Rosenberg-EPM Self-Esteem Scale) were used. Data were analyzed by using the Mann–Whitney and Friedman tests. Results 42 cases of breast cancer underwent oncoplasty breast conservative surgery in the study period (24 cases upfront surgery and 28 cases after neoadjuvant chemotherapy. Control group comprised of 59 cases of conventional breast conservation surgery (35 cases of upfront surgery and 24 cases after neoadjuvant chemotherapy). The group were matched for age, demographic and tumor characteristics. At postoperative month 12, the OBS group had significantly better health status than the control group with regard to role emotional (p < 0.02) health perception (p < 0.01), vitality (p < 0.05), and self-esteem (p < 0.02). The two groups were similar in physical functioning (p = 0.5), social functioning (p = 0.18), and mental health (p = 0.28) Compared to their preoperative scores, OBS group scores were significantly higher at 12 months for five of the eight dimensions of the Short Form-36: health perception (p < 0.02), vitality (p < 0.01), social functioning (p < 0.02), role emotional (p < 0.05), and mental health (p < 0.02). Self-esteem was also significantly better at 12 months (p < 0.02). Conclusion Oncoplastic surgery had a positive impact on quality of life and self-esteem of patients undergoing breast-conserving treatment. It had better quality of life asscociated with it that standard BCS group.

PS114

An Institution experience of Multiorgan resections in advanced colorectal malignancies: A Retrospective Analysis.

Ravisankar P, Ramakrishan AS

Background: Currently, the colorectal cancer is the most common gastrointestinal malignancy. Therefore, radical surgical treatment are required for the patients in whom tumor enlargement places them in T4. Methods: Medical records of 60 patients of colorectal malignancies who underwent multi organ resections between 2002 and 2012 in Cancer Institute (WIA), Chennai were reviewed. The demographic profile, site of the tumour, histology, upfront CEA values, type of organs resected, Staging, recurrence pattern, Disease free survival(DFS), Overall survival(OS) were analysed. Results: A total of 60 patients (Male-28 patients and females-32 patients, Age (22–73 years, Median -52.5 years) were analysed. 51.7 % cases had rectal malignancies followed by Sigmoid colon and ascending colon with 15 % each. Two patients had synchronous colorectal malignancy. Predominant histology being adenocarcinoma (76.7 % of patients) followed by mucinous carcinoma. Distant metastasis was found in 3 patients. Twenty-seven patients received Neoadjuvant treatment. The predominant organ resections include bowel resections in 31.7 % of patients followed by pelvic exenterations (26.7 % patients). 28.3 % of patients had wound related morbidity and one patient had immediate post operative mortality. The mean time of follow up was 46 months (Median 34.5 months). Twenty-two patients (36.7 %) had recurrence with 15 patients recurring distally. The mean time of recurrence was 19.6 months (2–63 months, Median 13 months). The 5 years DFS and 5 years overall survival for Stage II and III tumours are 52 % each and 70 %, 57 % respectively(p-0.094). Serum CEA done in 49 patients upfront and has shown significant difference in overall survival in patients below and above 10 ng/ml. Conclusion: Multi-organ resections in advanced colorectal malignancies offer potential curative treatment with acceptable morbidity. Keywords: Multi-organ resections, Advanced colorectal cancers.

PS115

METACHRONOUS PRIMARY: CASE REPORT AND REVIEW OF LITERATURE.

Gaurav Agrawal, Dr Megha Mittal, Dr Amit Agrawal, Dr S B L Shrivastav.

Patients with one form of cancer are known to possess a higher risk for development of a second tumor, presenting synchronously or metachronously over time. Distinguishing whether the second tumor represents a de novo cancer or a recurrence/metastasis of the first cancer has important implications for treatment and prognosis and specific clinical and pathological evidence is sought to resolve this issue. De novo cancer formation is favored by long latency interval (usually exceeding 5 years), better differentiation in the subsequent tumor, solitary second tumor formation and occurrence of the later tumor in a site not typical of metastatic spread. Conversely, recurrent metastatic disease is favored by short interval to second cancer formation, similar histology with increased anaplasia in the second tumor and lack of in situ malignancy and multifocal tumor deposits. While these criteria are sufficient in most instances to distinguish between the two, varying degrees of uncertainty can persist with a minority of cases remaining unresolved.

PS116

CERVICAL CORD COMPRESSION AS INITIAL PRESENTATION OF PAPILLARY THYROID CARCINOMA: A CASE REPORT

Shubha Garg, Veda Padama Priya Selvakumar, Akshay Tiwari, Ashish Goel, Kapil Kumar, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre., Sector -5, Rohini, New Delhi, Email: shubha_mbbs99@yahoo.com

Introduction: Cervical cord compression secondary to extension of a long standing papillary thyroid carcinoma as well as multiple cases of distal cord compression from occult follicular thyroid carcinoma have been reported. But cervical cord compression from PTC has not been reported so far. Case Summary: 48 years old lady presented with progressive quadriparesis of 2 months duration. MRI of the cervical spine showed destructive lesion with soft tissue component in vertebral bodies and posterior elements of C4-C6 vertebrae with cord compression along with a large thyroid mass extending to retrosternal region likely malignant. USG guided FNAC & Biopsy of thyroid lesion was inconclusive. Preoperative Selective angioembolisation for vertebral metastasis was done. Total thyroidectomy with cervical cord decompression, bone grafting and plating was done. HPE reported follicular variant of PTC. Radioiodine ablation was done by 263mci of I131 4 weeks post operatively. Initially she showed signs of neurological improvement but worsened 1 month later. She then received palliative EBRT to cervical and dorsal spine 30 Gy/10 fractions. She is alive with stable disease at 4 months follow up. Discussion Papillary thyroid carcinoma with cervical cord compression as initial presentation is rare. Therapeutic interventions should be directed to restore the integrity of the spine. The management usually includes a combination of surgery both of primary and decompression, radioiodine therapy, selective embolisation, bisphoshonates and radiotherapy. Conclusions Papillary thyroid carcinoma has an excellent prognosis. Hence a prompt management of primary disease and aggressive approach to metastatic lesion may prolong survival and allow favorable prognosis.

P S117

Case of HBsAg positive solitary plasmacytoma of the maxilla.

Dr. Rajkumar. P.N., Dr. Sabitha, Dr. Prakash, Kidwai Memorial Institute of Oncology, Dr. M.H. Marigowda Road, Bangalore – 560029, Karnataka, India. mail id: dr.rajpn@gmail.com

Aim - Plasma cell neoplasms have been classified as multiple myeloma(MM), solitary bone plasmacytoma (SBP), and extramedullary plasmacytoma (EMP). They account for approximately 3 % of plasma cell tumors and for less than 1 % of head and neck tumors. The solitary bone plasmacytoma of the maxilla is a rare condition that focuses solely on myelomatous tissue and is not disseminated to other parts of the skeleton. We present a case of a 55 years old HBs Ag + ve female patient suffering from an solitary plasmacytoma of bone (SPB) of the right maxillary sinus.Methods - The dense plasma cell infiltration with inflammatory lesions within the oral tissues makes diagnosis of plasmacytoma difficult. The patient underwent incisional biopsy and diagnosis confirmed by IHC. The diagnosis was based on a mass of clonal plasma cells separate from bone or bone marrow without evidence of occult disease elsewhere. The neoplastic cells had a large, single eccentric nucleus, resembling typical plasma cells. CT scan showed that the tumor mass occupied the right maxillary sinus and invading the orbital floor. M-protein present in serum and absent in urine. Radiation therapy is the primary treatment and dose was 60 Gray over 6 weeks. Surgery is not indicated for SBP. Result - Local control was achieved with radiotherapy and patient is on regular follow up. Disappearance of myeloma protein occurred and patient is disease free. Conclusion - Radiation therapy achieved excellent locoregional control of SBP. Plasmacytoma may present in the oral cavity or sinu-nasal region and be part of a systemic disease like multiple myeloma. A high index of suspicion and thorough initial histopathological work-up may help in establishing a definitive diagnosis and providing optimum treatment.

PS 118

STERNAL RESECTION & RECONSTRUCTION FOR MALIGNANT PHYLLOIDES TUMOR

Veda Padma Priya Selvakumar, Dharma ram, Manish Agarwal, Ashish Goel, Juhi Agarwal, Sandeep Mehta, Kapil Kumar, Dept of Surgical Oncology, RGCI&RC, Delhi-85. Email: privedsri@gmail.com

Aim: To report a novel technique of Biopore high density porous polyethylene (PHDPE) prostheses for total sternal and chest wall reconstruction for recurrent malignant phylloides tumor. Case Summery: Forty-nine years old premenopusal lady with no comorbidities was diagnosed phylloides tumour left breast in 2009. She underwent wide local excision in 2009. She developed recurrence for which she underwent a re-resection and later mastectomy in may 2012. She then underwent adjuvant radiation in June 2012. She presented to RGCI in march 2014 with recurrent swelling left chest wall of 5 months duration. PET CT revealed a heterogenous mass lesion 12.7 × 9.7 × 16.5 cm involving the sternum and left 2nd to 5th ribs abutting mediastinal vessls, pericardium and diaphragm. She was optimized and underwent complete sternal and chest wall excision of pectoralis major/minor/all intercostal muscles, left 2nd to 6th rib, left rectus origin from 7th rib and part of external and internal, oblique and transverse muscles. The first layer of reconstructive matrix consisted of prolene mesh sutured with prolene. The bony skeleton was reconstructed with Biopore polyethylene (PHDPE) prosthesis (blocks of 4 and 6 mm) to replace sternum. The three ribs on left side made by longitudinal tiles of PHDPE fixed with plates and screws and ethibond 1-0 suture. The 3rd layer of soft tissue defect closed with latissimus dorsi myocutaneous flap taken from ipsilateral back.

Post op recovery stable and she is receiving adjuvant IA based chemotherapy. Conclusion: Total sternal resection poses reconstructive challenge with respect to volume of defect, skeletal framework and respiratory mechanics esp when associated with chest wall excision. Biopore High density porous Polypolyethylene prosthesis is safe and suitable for total sternal reconstruction.

PS 119

RETROPERITONEAL CASTLEMAN’S DISEASE- A RARE DIAGNOSIS

Sandeep Kaul, Shaui Zaidi, Deepshiekha Arora, Department of Surgical Oncology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, Email-Id:- drsandeepkaul@yahoo.com

Introduction: Castleman’s disease, or giant lymph node hyperplasia, is an unusual lymphoproliferative disorder. It was first described by Castleman and Towne in 1954. Little is known about the cause of this disease, which may occur anywhere along the lymphatic chain, but it is most commonly located in the mediastinum. It usually presents as a localised soft tissue mass in the neck or the mediastinum; however, it has also been reported that the mesentery, pelvis, pancreas, adrenal and retroperitonuem may also be included in other extrathoracic involvement. The pathogenesis of that disease is known to be related to the human herpes virus 8 (HHV8). Generally, the disease is divided into two groups depending on its histologic and clinical features. In 1972, Keller et al. subclassified CD into a hyaline-vascular (HV) type and a plasma-cell (PC) type based on their histologic features. Some patients have a mixed form. Clinically, CD can be divided into a localized form, which refers to a unicentric (UC) disease, and a generalized form, which refers to a multicentric (MC) disease. Majority of CD are in the mediastinum(46 %) and only 39 % are in the abdomen. About a 1000 cases have been reported in literature but only a few are retropancreatic. We report a case of large retropancreatic hyaline-vascular unifocal castleman disease. Case Report: A 61 year old male presented to our outpatient department with a history of incidentally detected retropancreatic mass 81 × 61 mm in between the portal vein and inferior venacava with internal calcification. The patient was counselled regarding the need for laparotomy. After PAC & informed consent patient underwent a laparotomy via subcostal incision with complete excision of the mass.(fig 1 &2). The limits of surgery can be appreciated by studying the ct scan(fig. 3). The histopathology report was a pleasant surprise as hyaline-vascular unifocal castleman disease Conclusion: Castleman disease should be kept in mind in the differential diagnosis of a retroperitoneal mass not arising from any delineable structure.

PS120

A RETROSPECTIVE ANALYSIS OF SALVAGE NECK DISSECTIONS AFTER DEFINITVE RADIATION/CHEMORADIATION IN HEAD AND NECK SQUAMOUS CELL CANCERS

ORAL/pOSTER PESENTATION

Dr Karthik Chandra Vallam, - Surgical oncology Registrar, Tata Memorial Hospital

Dr A. Deshmukh - Assistant Professor, Head and Neck Oncology, Tata Memorial Hospital,

Dr S.G. Laskar - Professor, Radiation Oncology, Tata Memorial Hospital

Dr DA Chaukar - Professor, Head and Neck Oncology, Tata Memorial Hospital

Dr AK D’ Cruz - Professor, Head and Neck Oncology, Tata Memorial Hospital.

Aim Chemoradiation has become the mainstay of treatment for seclected patients with locally advanced laryngopharyngeal cancers with the aim to preserving organ and function without compromising control rates. Following treatment with definitive radiotherapy or chemoradiation, salvage neck dissection may be necessary in some patients who have residual or recurrent neck node or have developed recurrent neck disease. In this study, we have analysed salvage neck dissections done at our Institute which is a large, tertiary cancer centre in India. The objective of this study were to determine the disease free survival rate post salvage neck dissection, to identify factors influencing survaival outcomes post salvage neck dissection and to determine patterns of recurrence post salvage neck dissection. Methods The study was initiated after approval from the Institutional Review Board (IRB). Data was collected restrospectively from patients’ case records, and electronic medical records. All head and neck squamous cell cancer patients who have received radiation alone or chemoradiation as the primary treatment modality followed by salvage neck dissection (modified radiacal or radical) for isolated neck residual disease or recurrence. All salvage neck dissections done from 2006 to 2011 at aour includede for this analysis. Results 114 salvage neck dissections were done during the study period. However, only 69 SNDs met our eligibility criteria. The recurrence free survival rate calculated by the Kaplein-Meier analysis was 21.7 % at 2 years. On univariate analysis, only 3 factors appeared to have significant association with RFS - extended radical neck dissection, extra-nodal deposits, positive histopathology. On multivariate analysis the need for an extended radical neck dissection alone emerged as a significant factor influencing the RFS post SND. (Cox regression analysis, p = 0.023). Conclusions Salvage neck dissection should be offered in all patients having residual/ recurrent disease after completion of definitive chemoradiation, where the primary is controlled. The recurrence free survival after the procedure is a function of the extent of surgery, also reflecting the extent of nodal disease.

OR 121

Extra-hepatic bile duct resection: An insight in the management of gallbladder cancer

Jyoti Sharma, Durgatosh Pandey, Pankaj Kumar Garg, Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India

Aim To analyze the outcome of extrahepatic bile duct resection in gallbladder cancer. Methods This retrospective study was done in two tertiary teaching hospitals of North India. The case records of all the patients who underwent radical cholecystectomy with extra-hepatic bile duct resection were reviewed. Details concerning the clinical presentation, preoperative therapy, operative procedure, indication of bile duct resection, postoperative complications and outcome were retrieved from the case records. Kaplan Meir analysis was done to find out median disease free survival and overall survival. Results There were 14 gallbladder cancer patients who underwent radical cholecystectomy with resection of extrahepatic bile duct. Median age of the patients was 51.5 years; male to female ratio was 2:5. Five patients were diagnosed after histopathological examination of resected gallbladder specimen following cholecystectomy (incidental gallbladder cancer). All the patients had R‘0’ resection. The indication for extra-hepatic bile duct resection was direct infiltration in nine, positive cystic duct margin in two, densely adherent pericholedochal lymphnodes in one and associated ampullary growth in one patient. Kaplan Meier analysis predicted median disease free survival of 20 months and median overall survival of 24 months. Conclusion Extrahepatic bile duct resection to achieve R‘0’ resection in the management of advanced gallbladder cancer is associated with improved survival.

OR 122

Malignant Perforation Peritonitis: Challenge to a General Surgeon in emergency

Dr. Puneet Malik, B. L. Yadav & Rajveer Arya, Department Of General Surgery, Sms Hospital, Jaipur. Address: 526/53 civil lines, malik dairy, Roorkee-247667, Email id: dr.puneetmalik@gmail.com

Aim: This study was done to know the spectrum of etiopathology, clinical presentation, management and treatment outcomes of patients admitted with malignant perforation peritonitis in our hospital. Methods: A prospective study was done over a period of 3 years from January 2011 to December 2013 in a tertiary centre which included 1400 patients diagnosed with perforation peritonitis. Seventy-eight cases were found to have malignant perforations. We collected data on age, sex, tumour stage, histological finding, surgical treatment, morbidity and mortality. Results: Majority (62.8 %) were males. Mean age of presentation was 59.1 years. The time taken for resuscitation and preparation of patient for surgery was less than 12 h in 83.4 % patients. Most common symptom with which patient presented was abdominal pain (99 %) followed by nausea and vomiting (85 %), abdominal distension(71 %) and altered bowel habit(62 %). Eighty-six percent cases had colorectal perforation followed by gastric (11.5 %) and small intestinal (2.5 %) perforations. 82.3 % had advanced tumour stage. Majority of colorectal perforation patients underwent Hartmann’s procedure (88.1 %). 55.5 % of gastric perforations underwent gastrectomy. Intestinal perforation cases underwent resection and anastomosis. 52.5 % patients received chemotherapy. Complications included wound infection (31 %), electrolyte imbalance (19.5 %), pneumonia (23 %), septicaemia (9 %), renal failure (8 %), intraabdominal abscess (6 %). Mortality rate within 1 month was 30.7 %. Conclusion: In developing countries with limited resources, ignorance, financial constraints and lack of specialist medical knowledge, perforations associated with malignancies are quite common and lead to increased morbidity and mortality.

OR 123

STAGING LAPAROSCOPY FOR CARCINOMA OF STOMACH: ARE WE MAKING A DIFFERENCE?

Dr Dinesh M G, Dr Sandeep P Nayak, Dr C Srinivas, Dr M Vijayakumar, Department of surgical oncology. Kidwai Memorial Institute of Oncology, Dr. M.H. Marigowda Road, Bangalore – 560029, Karnataka, India. mail id - drdineshmg@gmail.com

Background: Since many patients with gastric cancer present with locally advanced or metastatic disease, accurate staging aids in appropriate treatment selection. Even after high resolution computed tomography for staging of gastric tumors, few patients are found to have unsuspected, unresectable disease at exploration. In this study we are looking at the utility of staging laparoscopy as an investigative tool to assess, if it makes any difference in the management of such patients. Materials and Methods: This was a prospective study conducted on 28 patients of endoscopic and biopsy proven gastric carcinoma that were found to be operable on HRCT of abdomen & pelvis from May 2013 to May 2014 at our institute. Staging laparoscopy was done as a part of workup and if found operable, cases were subjected to curative surgery. The results were further assessed using statistical methods. Results: Of the 28 patients 10 (35.7 %) cases were found operable after laparoscopy and in all these cases radical gastrectomy was done. Exploratory laparotomy was avoided in 7 (25 %) cases. Eleven (39.28 %) patients with obstruction underwent either GJ/FJ with a mini laparotomy incision. Sensitivity, specificity and diagnostic accuracy of HRCT abdomen & pelvis is 100, 5.88 & 39.28 % respectively (to assess operability). Sensitivity, specificity and diagnostic accuracy of staging laparoscopy is 100, 94.4, 96.4 % (to assess operability). Metastatic disease was found in 13 (46.4 %) cases & advanced disease in 18 (64.3 %) cases on staging laparoscopy. Conclusion Staging Laparoscopy is an important tool in staging of carcinoma stomach. In our study staging laparoscopy made a difference in the management of 25 % of patients. We feel that adding staging laparoscopy to the management of gastric cancer patients makes a major difference and benefits the patient.

OR 124

Analysis of Tumor Length and Clinicopathologic Features in Carcinoma Esophagus.

Pampanagouda S K M (a), Sailaja Suryadevara (a), Veerendrakumar K V (b), Vijayalakshmi Deshmane (b), Dept of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore. Email: drpampanagouda@yahoo.co.in

Aim: - Even with multidisciplinary team approach, the prognosis of Esophageal Cancer (EC) has not significantly changed. Studies are required to explore the other prognostic factors which might alter the outcome. Our study aims at analyzing the esophageal tumor length with stage of the disease, and clinicopathological features. Methods: - 150 patients with esophageal carcinoma who underwent curative surgery without neoadjuvant chemotherapy and or radiotherapy are included in the study. Formalin fixed esophageal tumor length was measured. Tumor length was analyzed with respect to overall stage, T stage & N stage of the disease. Results: - Male to female ratio was 90:60, with a median age group of 55 years (Range - 30–78 years). Median tumor length was 4 cms. Of these 150 patients, 29 % of patients had disease at the middle third, 44 % at the lower third, & 27 % at the esophagogastric junction. Squamous cell carcinoma was diagnosed in 85 % (127) of patients & adeno carcinoma in 15 % (23) of patients. Patients with tumor length of 4 cm or less had 4 % T1 lesions, 17 % T2 lesions, 36 % T3 lesions, & 5 % T4 lesions. Patients with tumor length of more than 4 cm had no T1 lesions, but had 7 % T2 lesions, 29 % T3 lesions, & 2 % T4 lesions. Among patients with tumor length of 4 cm or less, 5 % were in stage I, 25 % in stage II, 32 % in stage III. In patients with tumor length more than 4 cm group, 2 % of patients presented in stage I, 21 % in stage II, & 15 % in stage III. More number of patients presented with lymph node positivity among patients with tumor length of 4 cm or less (34 %) compared to patients with tumor length of more than 4 cm (17 %). Conclusion: - From our study it is evident that tumor length may have an impact on stage of presentation of the disease. This will consequently have bearing on the prognosis of the disease by guiding proper stratification of the disease on the basis of length of the tumor, and institution of therapy. Further well planned studies might bring more evidence on this aspect with respect to impact of tumor length on survival. Key words: - Esophageal carcinoma, Tumor length.

OR125

Prognosis and survival of patients with Carcinoma Penis - Tertiary health centre study

Ankit Shah¹,B. B. Pandey, Mahavir Cancer Sansthan, Patna, Bihar, E mail id: 1- ankitdr86@gmail.com

Abstract Aim The major issue in penile cancer is deciding whether patient should undergo lymph node dissection or not. Aim of this study is to find out relation of various prognostic factors of Carcinoma penis (clinical, histo-pathological, type of treatment etc.) with the various outcomes after at least 5 years. Methods Each patient who was diagnosed as having carcinoma of penis by incision biopsy and operated from January 2004 to May 2009 at the institute Mahavir Cancer Sansthan was included in the study (N = 117). Data was collected by review of records for various clinical factors (age and clinical T and N stages); pathological factors (histological type and grade, lymphovascular invasion, infiltration of the corpora cavernosa, corpus spongiosum and urethra with involvement of nodes by tumour cells). Data was entered and analysed in Microsoft Excel spreadsheet and analysed by epi info version 3.5.3. Results 30 patients died before 5 years (Mean = 26 months). Recurrences (Local or systemic) were seen in 23 patients (Mean = 17.4 months). Five years Disease Free Survival (DFS) was 80.34 % and Overall Survival (OS) was 72.22 %. Keplan Meier analysis showed that keratinizing squamous cell histology, well to moderately differentiated grade, lymphnode negative disease and low stage have higher survival than Non-keratinizing histology, poorly differentiated grade, lymphnode positive disease and higher stage respectively. Multiple logistic regression analysis revealed that inguinal lymphnode positivity and Grade were significantly associated with local or systemic recurrence. Bivariate analysis revealed Ilioinguinal block dissection, Non-keratinizing histology, higher grade, inguinal node positivity, iliac node positivity, lymphovascular invasion, higher stage and defaulter to adjuvant treatment were significantly associated with recurrence. Conclusion Lymph node metastasis on presentation is most important prognostic factors in carcinoma penis so groin node dissection should be considered in all suspicious cases.

OR126

Extralevator adomino perineal resection – Short term oncological and clinical outcomes in comparision with conventional procedure.

Vishwas Pai, Ashwin Desouza, Jean, A P Saklani, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India- 400012.

Objectives: Feasibility of extralevator abdomino perineal resection [EAPER] with regard to the circumferential resection margin [CRM] and post operative complications. Material and methods: Patients with low rectal cancer who underwent abdomino perineal resection in TMH during the period of 1 year from July 2013 to June 2014 were included. All patients underwent standard set of investigations for proper staging and those with threatened circumferential resection margin (CRM) were given preoperative chemoradiotherapy whereas others were offered upfront surgery. Surgery was performed 6–10 weeks after the end of chemoradiotherapy. Short term oncological outcomes included CRM and number of nodes dissected. Clinical outcomes included post operative wound complications, need for plastic reconstruction and hospital stay. Results: Seventy eight patients with low rectal cancers underwent abdomino perineal resection during the defined study period. Out of these nineteen had undergone EAPER. Among those who underwent EAPER, 12 (63 %) underwent open resection and rest underwent laparoscopic resection. Plastic reconstruction was done in 3 (15 %) with prolene mesh also used in one of the patients. Median blood loss was 500 ml and median hospital stay was 9 days. Four (21 %) developed wound complications and majority were managed conservatively. Circumferential resection margin was involved in 1 patient and median number of nodes was dissected was 9. Intra operative rupture occurred in two patients. Conclusions: Extralevator abdomino perineal resection is associated with significantly lower circumferential resection margin involvement and is associated with accepted perioperative morbidity.

OR 127

A COMPARITIVE STUDY OF OESOPHAGECTOMY BY THORACOSCOPIC ESOPHAGECTOMY AND ROBOTIC ASSISTED ESOPHAGECTOMY

Ashrit Reddy Cheruku, ashrithmedico@gmail.com,

AIM: TO COMPARE PERIOPERATIVE AND POSTOPERATIVE OUTCOMES IN THOROCOSCOPIC VERSUS ROBOTIC ASSISTED ESOPHAGECTOMY WITH 3 FIELD LYMPH NODE DISSECTION FOR OESOPHAGEAL MALIGNANCIES. MATERIALS & METHODS: RETROSPECTIVE DATA OF PATIENTS DIAGNOSED WITH ESOPHAGEAL MALGNANCIES WHO UNDERWENT OESOPHAGECTOMY WITH 3 FIELD LYMPH NODE DISSECTION (THOROCOSCOPIC VERSUS ROBOTIC ASSISTED RESPECTIVELY) AT KRISHNA INSTITUTE OF MEDICAL SCIENCES FROM SEPTEMBER 2011 TO JUNE 2014. DATA COLLECTED AND ANALYSED BY SPSS SYSTEM. RESULTS: TOTAL OF THIRTY FOUR PATIENTS WHO UNDERWENT ESOPHAGECTOMY WITH 3 FEID LYMPH NODE DISSECTION THORACOSCOPICALLY (15) & ROBOTIC ASSISTED (19). IT IS NOTED IN ROBOTIC ASSISTED PROCEDURES THE LYMPH NODE YEILD (18–20) AND IN THORACOSCOPY (12–14), RECURRENT LARYNGEAL NERVE(RLN) INJURY THOROCOSCOPICALLY (5) AND ROBOTIC ASSISTED (0), BLOOD LOSS THOROCOSCOPICALLY(MEAN 230.67 ml) & ROBOTIC ASSISTED (MEAN 145.5 ml), CHYLE LEAK THORACOSCOPICALLY (3) & ROBOTIC ASSISTED (0), VENTILATOR SUPPORT THOROCOSCOPICALLY (MEAN 4 days) & ROBOTIC ASSISTED (MEAN 2.4 days), INTERCOSTAL DRAIN THOROCOSCOPIC (MEAN 2.5 days) & ROBOTIC ASSISTED (MEAN 4.2 days) & HOSPITAL STAY THOROCOSCOPIC (MEAN 10.2 days) & ROBOTIC ASSISTED (MEAN 7.2 days) CONCLUSION: THE ROBOTIC ASSISTED ESOPHAGECTOMY HAS SIGNIFICANT YEILD OF LYMPH NODES, BETTER IDENTIFICATION & PRESERVATION OF RLN AND THORASIC DUCT, EARLY POST OPERATIVE RECOVERY, LESS VENTILATOR SUPPORT & LESSER HOSPITAL STAY. ALL THESE ADVANTAGES MAKE ROBOTIC ASSISTED ESOPHAGECTOMY SUPERIOR TO THOROCOSCOPIC ESOPHAGECTOMY.

OR128

The clinical, pathologic profile, outcome and prognostic features of Primary peritoneal serous carcinoma

Dr. Shiva kumar H. C_1, Dr. Bafna U.D_2, Dr. Vijayalaxmi Deshpande₃

[Surg Onco], KMIO, Room 210. PG Hostel, Bangalore-29, Email; dr.hcshivkumar@gmail.com

Background: Primary peritoneal serous carcinoma (PPSC) rare malignancy arises primarily from peritoneal surface epithelium. However there are limited studies on these tumors even in world literature. AIM: To study the clinical, pathologic profile, outcome and prognostic features of PPSC. Material and methods: Five year retrospective study of PPSC diagnosed & treated at our centre was conducted. Pathological specimen of PPSC diagnosed from January 2008–December 2012 were reviewed by gynaeconcopathologists. Diagnosis based on GOG criteria, complemented with IHC. Majority patients underwent upfront de-bulking surgery. Postoperatively, six cycles of combination chemotherapy paclitaxel(175 mg/m²) and carboplatin(AUC6) administered every 3 weekly. Patients analysed for event free survival(EFS), this was correlated with stage and surgical adequacy. Results: Median age 56 years. Ovarian cancers treated during study period 374.10(2.7 %) of 374 were eligible for PPSC analysis. Two (20 %) of 10 cases had family history of breast and ovarian cancers, two (20 %) cases diagnosed-abdominal tuberculosis prior referral to our-centre. Radiological-presentation includes grossascites, with omentalcaking and normaladenexa. Eight (80 %) of 10 cases presented with stageIIIC and 2 cases (20 %) with stageIV disease. Eight (80 %) of 10 cases underwent upfront surgery; six (75 %) of eight cases had optimal cytoreduction, i.e. residual disease < 1 cm or no-visible disease and other 2 (25 %) suboptimal cytoreduction. Two (20 %) of 10 cases with stageIV disease received neoadjuvant chemotherapy (NACT) followed by interval cytoreduction. After debulking surgery most useful IHC marker include CK7+, CK20−, CA125+, WT-1+, and GCDFP−. At median follow up of 24 months (range; 3–60 months),median progression free survival (PFS) was 22 months, while the estimated 5 year PFS was 18 %. Stage IV disease and suboptimal surgery had poor outcome. Conclusion: PPSC presents with advanced stage disease and observed to be misdiagnosed abdominal TB in tropical countries. GOG criteria and IHC complement diagnosis. They have poor outcome despite optimal care, highlighting need for larger studies on this disease. Key Words: Abdominal TB, Primary peritoneal carcinoma, Regional cancer institute.

OR129

Axillary reverse mapping [ARM]

Dr Satish C, Dr Sunny Gandhi, Dr Vijaykumar DK, Dr Shanmuga Sundaram, Amrita Institute of Medical Sciences Kochi

Introduction: In breast cancer, axillary lymph node dissection does not distinguish breast from upper limb lymphatics. ARM identifies the upper limb lymphatics and its draining lymph node in axilla. Preservation of this node may reduce lymphedema. Aims: 1. To confirm the existence of a constant sentry node in the axilla that drains the lymphatics of the upper limb. 2. To find out the percentage of cases in which the ARM node harbours metastasis in clinically/pathological N0, N1, N2 and N3 disease. Material and Methods: Patients who had previous chemotherapy / axillary were excluded. One hundred breast cancer patients undergoing axillary clearance had an injection of radio-isotope into the dorsum of the hand A hand held portable gamma probe was used to identify the ARM node. Results: The ARM node was successfully identified in 94/100 cases. The location of the ARM node was found to be constant in about 80 % of cases (76/94). Of the 94 patients the ARM node harbored metastasis in 9 patients. Forty-five percent of patients with N3 disease 14 % patients with N2 disease and 4 % patients with N1 disease had metastasis in the ARM node. Conclusion: Axillary reverse mapping can successfully identify the sentinel node of the upper limb in 94 % of the patients. Anatomically the location of the node is fairly constant in 80 %. It is usually not involved in metastasis in early breast cancer.

OR130

Carcinoma Breast in Young women-is it a different disease? Retrospective study

Dr. Bharath V.M., Dr. Madhu Muralee, Dr. Iqbal Ahamed, bharathveerabadhran@gmail.com, Division of surgical oncology, Breast and G.I. services, Regional Cancer Centre (RCC), Medical College Campus, Trivandrum -11

Introduction: In kerala, women less than 35 years of age comprise to 7.8 % of total number of breast cancers, compared to 4 % worldwide. Pathologic data support the notion of younger patients having more aggressive tumor biology than older patients. But the exact reasons still remain unclear. We studied the survival outcomes of these young women to analyse whether stage at presentation, treatment received and biological characteristics contribute to the generally poorer outcomes in them. Materials and methods: For the purpose of this study, young age was defined as age less than 35 years. Clinical case records of patients operated in the Division of Surgical Oncology in RCC during the period January 1st 2006–December 31st 2009 was studied. Recurrences in the ipsilateral breast or regional nodes were considered as local events. All other recurrences were considered to be systemic recurrences. Results and discussion We have a median follow up 70 months (range 48–96 months). Number of isolated locoregional recurrences was 10 (4.06 %) and the number of distant metastases was 48 (19.51 %). Five years Overall survival was 85.5 % and Disease free survival was 76.7 %. Conclusion: To the best of our knowledge, this is the only study from India looking at this specific age group of patients. Our results are at best comparable if not better than the standard published data from other countries. We believe that though the tumour biology is poorer in this subset of patients, it is not a bad disease altogether.

OR131

RISK FACTORS FOR DEVELOPMENT OF LYMPHEDEMA FOLLOWING BREAST CANCER TREATMENT – A RETROSPECTIVE STUDY.

Ashwin Hebbar K¹., Krishnamurthy S², Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, E-mail- hebbar2000@yahoo.com

Aim: Lymphedema of the arm is a complication of breast cancer treatment that affects 10–35 % of breast cancer survivors. The pathophysiology of lymphedema following breast cancer treatment is poorly understood, probably suggesting a multifactor nature. As the breast cancer survival rate increases, lymphedema will potentially impact more women. The aim and objective of this study is to identify the factors associated with secondary lymphedema after breast cancer treatment. Methods: A retrospective study of 506 patients who underwent modified radical mastectomy for breast cancer in the department of Surgical Oncology at Kidwai Memorial Institute of Oncology between January 2009 and December 2013. Available follow up period varied from 8 months to 5 years. Inclusion criteria: female breast cancer patients, early & locally advanced breast cancer patients who underwent surgery and patients undergoing modified radical mastectomy as the surgical treatment. Exclusion criteria-male breast cancer patients, patients with distant metastases, patients with recurrent disease, patients undergoing breast conserving surgery, patients undergoing lumpectomy before presentation to our hospital. Results: Out of 506 patients studied 70 patients developed lymphedema. Among them 60 % patients were obese. Average nodes harvested were 13 and average nodes involved were around 4. Eighteen percent were belonging to stage II and 77 % belonging to stage III. Among those 70 patients 56 received radiotherapy to local and 39 received radiotherapy to axilla also. Sixteen percent patients presented with wound complication post surgically. Conclusion: Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Factors associated with increased risk of lymphedema following breast cancer treatment are presence of high body mass index, pathologic N2 disease, higher TNM stage and radiotherapy to axilla. Combination of axillary dissection and axillary radiotherapy should be avoided whenever feasible to avoid lymphedema. Since there is no ideal treatment available for established lymphedema, further efforts should be focused on optimizing treatment combinations in an effort to decrease the incidence of lymphedema.

OR132

Axillary lymph node ratio ‘LNR’ versus nodal stage ‘pN’ as a predictor of breast cancer survival.

D. Yadav*, G. Gopal*, K. Thakar*, M. Kumar*, A. Joshipura*, R. Patel*, P. Kshirsagar*, S.J. Pandya, Deptt. Of Surgical Oncology, GCRI.

Background: Compared to conventional pathological axillary nodal staging (pN), the LNR (i.e. the ratio of positive over excised lymph nodes) offers potentially improved prognostication, selection of adjuvant therapy and inter-institutional comparability. Cut-offs of 0.20 and 0.65 were proposed to classify patients into low, intermediate and high risk groups, in the largest study on the subject till date. We perform an independent external validation of the LNR concept in the Indian subcontinent. Material & Methods: 225 patients undergoing primary surgery for breast cancer at tertiary care centre in Gujarat, were retrospectively analyzed using Cox multivariate regression. Median follow up was 42 months (range 2 to 120 months). Results: Using the above cut-off points, 10 years disease free survival (DFS) rate of 74, 57 and 48 % and adjusted hazard ratio (HR) of 1.19 (95 % CI 0.33 to 4.37), 2.21 (95 % CI 0.75 to 6.51) and 6.88 (95 % CI 1.58 to 29.92; p = 0.01) were obtained for the low, intermediate and high risk groups respectively. The corresponding risks for the pN1, pN2 and pN3 categories were 1.74, 1.74 & 1.35 representating inadequate, even reversed prognostic stratification. On including both LNR and pN as continuous variables, the nodal ratio continued to remain prognostically significant with an adjusted HR of 12.33 (95 % CI 1.1–142.5, p = 0.04) in contrast to the node number (HR = 0.97, 95 % CI 0.9–1.1, p = 0.41). Conclusions: The LNR outperformed the pN staging in predicting DFS in our cohort of patients, irrespective of whether it was modeled as a categorical or continuous variable. Simultaneous inclusion with pN only increased its prognostic weight and resulted in exclusion of pN from the multivariate model. Our study thus provides independent external validation of the LNR concept and contributes to the growing body of literature supporting the incorporation of a ratio-based system into breast cancer staging.

OR133

Five year retrospective analysis of triple negative breast cancer in a tertiary care cancer centre.

G. Gopal*, D. Yadav*, K Thakar*, M. Kumar*, A. Joshipura*, R. Patel*, P. Kshirsagar*, S.J. Pandya, Deptt. Of Surgical Oncology, GCRI.

Aim of study: Female breast cancer is about 10 % of total cancer in our institute. This analysis was done to see triple negative among these patient with their survival strength up to 5 years in different age group, Stage and chemotherapy protocols. Material and methods: 200 IHC proven TNBC patients registered and treated till 2012 were retrospectively selected for the study. Overall survival up to 5 years was observed on the basis of stage and different age groups and chemotherapy regimen. All patients had surgery, conventional EBRT and adjuvant chemotherapy. The survival analysis was performed using the Kaplan-Meier method. Results: Majority of patients (41 %) were in age group 21–30 years. Stage IV was seen in 18 % of patients at diagnosis and mainly in 21–40 years age group. Only 3 % females were >70 years and were of stage I and II. Overall 5 years survival in stage I in CAF/CEF group was 37.5 % as compared to TE group 93 % (p < 0.0001). About 41 % were in younger age group. At time of diagnosis 18 % of patients were of stage IV of which mainly in 21–30 years age. Conclusion: Triple negative in GCRI is about 11.8 %. We observed it mainly in younger patients with highly aggressive behaviors. Taxane based chemotherapy gives better result as compared to anthracycline based regimens (p < 0.0001). However ours being a retrospective analysis, we feel that a prospective randomized control study can be carried in Indian scenario.

OR134

Utility of [18F]Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) in the initial staging and response assessment of locally advanced breast cancer patients receiving neoadjuvant chemotherapy

Narendra H¹, Reddy SG¹, Kalawath TC², Lakshmi AY³, Radhika K⁴.

¹Department of Surgical Oncology, ²Nuclear Medicine, ³Radiology, ⁴Pathology

Sri Venkateswara Institute of Medical Sciences, Tirupathi-517507, drnarendrah@yahoo.co.in

Introduction: In India up to 50 % of breast cancer patients still present as locally advanced breast cancer (LABC). The conventional methods of metastatic work up include physical examination, bone scan, chest & abdominal imaging, and biochemical tests. It is likely that the conventional staging underestimates the extent of initial spread and there is a need for more sophisticated staging procedure. The PET/CT can detect extra-axillary and occult distant metastases and also aid in predicting response to chemotherapy at an early point in time. Aim: To evaluate the utility of FDG PET/CT in initial staging and response assessment of patients with LABC receiving NACT. Methods: A prospective study of all biopsy confirmed female patients diagnosed with LABC receiving NACT from April 2013 to May 2014. The conventional work up included serum chemistry, CECT chest and abdomen and bone scan. A baseline whole body PET/CT was done in all patients. A repeat staging evaluation and a whole body PET/CT was done after 2/3rd cycle of NACT in non-responders and after 3/4 cycles in clinical responders. The histopathology report of the operative specimen was used to document the pathological response. Results: The FDG PET /CT reported distant metastases in 11 of 38 patients, where as conventional imaging revealed metastases in only 6. Almost all distant lesions detected by conventional imaging were detected with PET/CT, which showed additional sites of metastasis in 3 patients. In 2 patients, PET/CT detected osteolytic bone metastasis which were not detected by bone scan. In 5 patients PET CT detected N3 disease which were missed on conventional imaging. A total of 14 patients had second PET/CT done to assess the response to NACT and 11 patients underwent surgery. Two patients had complete pathological response. Of these 1 patient had complete metabolic and morphologic response and other had complete metabolic and partial morphologic response on second PET/CT scan. Conclusions: 18 FDG PET/CT can detect more number of metastasis as well as additional sites of metastasis compared to conventional methods. The response assessment resulted in change of treatment regimen in 14 % of patients.

OR135

Breast as an unusual site of metastasis- series of 3 cases and review of literature.

Shashidhar K1., Krishnamurthy S², Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, e-mail– drshashi75@rediffmail.com

Background and objectives: Metastasis to the breast from extra mammary sites is uncommon with an incidence ranging from 1.2 to 2 % in clinical reports. Approximately 300 cases of breast metastasis from extra mammary sites have been reported, mostly in small series or as a single case report. Gastrointestinal adenocarcinoma metastasising to the breast is also very rare and only 30 cases have been reported in the literature. Metastatic deposits within the breast may be difficult to distinguish from primary breast carcinoma. Radiological features and immunohistochemistry especially for steroid hormone receptors (ER/PR) and expression of gross cystic disease fluid protein (GCDFP) and presence of other immunohistochemistry protein factors in breast metastasis which are specific to primary site may be helpful in differentiating these two conditions. Materials and methods: In this series of 3 cases of breast as an unusual site of metastasis, we present different cases of adenocarcinoma of stomach, sigmoid colon and kidney with metastasis to the breast and discuss the differential diagnosis and management plans. Conclusion: In conclusion, secondary tumors to the breast are rare and thus differentiating primary tumors from metastatic breast carcinoma is important for rational and optimum therapy and avoidance of unnecessary radical surgery. Palpable breast lump without typical radiological signs of primary breast carcinoma in patients with known primary should be suspected of representing metastasis.

OR136

Evaluation of Oncoplastic Breast Surgery in the management of carcinoma breast patients treated with neoadjuvant chemotherapy

Ashutosh Chauhan, Mala Mathur Sharma, Malignant Disease Treatment Center, Command Hospital(CC), Lucknow,bolubonkey@rediffmail.com

Aim: To evaluate the benefit of Oncoplastic Breast Conserving Surgery (OBS) compared to standard BCS after primary CT, in terms of oncologic safety and cosmetic outcomes. Methods: A retrospective study spanning Jun 2012 to Jun 2014, we identified 119 patients who were treated with breast conservation surgery after neoadjuvant chemotherapy. Out of these, patients who underwent Oncoplastic Breast Surgery (OBS) were identified as Group A and those who underwent BCS were identified as Group B. Median operative specimen volume, tumor size and margins attained in either group were noted. Also noted was re-excision rates and mastectomy rates. Results: A total of 35 OBS and 84 standard BCS were analyzed. The median tumor size was 42 mm in the two groups (p ¼ 0.66). The mean operative specimen volumes were larger in the OBS group than in the standard group (respectively, 191 cm3 and 103 cm3, p < 0.01). Re-excision (5 vs 14 %) was higher in Group B while mastectomy (2 % vs 5 %) rates were similar (p = 0.04 and p = 0.30). Mean margins achieved in Group A were 11 mm(+/− 4 mm) while those in Group B it was 7 mm(+/− 3 mm) respectively. Conclusion: OBS allows excision of larger volumes of residual tumor after neoadjuvant CT. and wider margins are possible.

OR 137

Decision making factors among early breast cancer patients in choosing breast-conservation surgery or modified radical mastectomy.

Gargi S Kumar, Vidhubala E, Sri Devi V

Background: Modified Radical Mastectomy (MRM) or Breast Conservation Surgery (BCS) accompanied by radiation therapy produce equal outcome in terms of survival among Early Breast Cancer Patients (EBCP). However, majority of the women opt MRM though offered BCS due to various factors. The current study is to identify the decision making factors among EBCP in choosing BCS or MRM. Method: EBCP (n = 44) enrolled between January and June 2014 at the Cancer Institute, suitable to undergo BCS were interviewed once they chose the treatment. A semi structured interview was conducted using four key questions (the options given, understanding about the options, person who made the decision and the factors which helped them to decide MRM or BCS. After taking the consent, verbatim of interview were recorded and content was analyzed. Result: Age ranged from 29 to 78 years. All the 44 patients were offered both options and they reported that they understood the implications of both the options such as the procedure, additional treatment modality required (radiation therapy), duration of treatment and hospital stay, treatment outcome such as survival, body image, etc. Of the patients, 10 chose BCS and 34 chose MRM. The patients reported that the decision was made by themselves, family members and doctors. The factors which made them to choose MRM were fear of recurrence, additional treatment (radiation therapy), duration of treatment, logistics and family issues. The patients believed that MRM will have a better survival. This was due to the interaction with other patients underwent MRM and second opinion sought elsewhere. The reasons for choosing BCS were doctor’s advice, body image and self esteem. Conclusion: Despite the options and benefits explained by the doctors, the psychosocial factors and the previously treated patients found to play a role in making decision among EBCP. The patients and the family members need to be empowered to make the decision thereby making the breast conservation possible for suitable patients. Exploring further to understand the influential factors through a systematic study will help us to provide appropriate support to the patients to help in the decision making process.

OR138

EFFICACY OF CONTRAST ENHANCED MRI AS A NON INVASIVE STAGING TOOL IN CLINICALLY NEGATIVE AXILLA IN EARLY BREAST CANCER

Syam Virkam, Jem Prabhakar, Madhu Muralee, Arun Peter, Sumod Mathew*, Surgical Oncology, * Radiodiagnosis, Regional Cancer Centre, Thiruvananthapuram

Aims and objectives: AIM: To determine whether a high spatial- resolution, contrast enhanced MRI of the axilla can be used as an oncologically safe non-invasive diagnostic tool for nodal metastasis in early breast cancer. This study is an effort to bring down the morbid long term complications of axillary dissection. Methods: Prospectively conducted study. Forty-eight patients with cytologically proven small breast tumors (Tumors up to 3 cm in size) with a clinically node negative axilla. Clinically node negative axilla is defined as any axilla where there is no identifiable axillary node by clinical examination. Ultrasonogram used in suspected cases. Two patients had bilateral breast cancer and thus we have studied 50 axillary dissections. Irrespective of the MRI findings all patients underwent axillary. Pathologist was blinded about the MRI finding. Adjuvant treatment was given according to standard recommendation. Results: Sensitivity of MRI in our study, in diagnosing a metastatic lymph node, is 84 % and is comparable to the literature (80–100 %). Specificity is 60 %, which was not an encouraging value. Our study shows a Positive predictive value (PPV) of 68 % and a Negative predictive value (NPV) of 80 %. Though it is desirable to have a NPV of 100 % for a diagnostic tool our result is encouraging. Accuracy in our study is 72 %. Conclusion: With very limited resources we could get a very encouraging result. We can achieve a more standardised which are comparable with western literature by conducting further studies thus reuce morbidity of our patients.

OR 139

TO DETERMINE THE EFFICACY AND SAFETY OF RADIO FREQUENCY ABLATION IN THE TREATMENT OF OSTEOID OSTEOMA.

Dr R. Balaji (post graduate), Prof. P. Gopinath menon M.S Ortho, Asst. Dr Srinivasa rajappa M.S. Ortho, Sri ramachandra Medical university, porur, chennai-600116.

Aim: Osteiod osteoma can be efficiently treated by radiofrequency ablation with minimal morbidity and early return to function. Methods: In our institution from 2012 to 2014, we had 12 patients have been diagnosed to have osteiod osteoma clinically and radiologically with nidus size less than 15 mm was and not relieved by NSAIDs treated with radio frequency ablation a set temperature 90° for 6 min under ct guidance. All patients were assesed by VISUAL ANALOGUE PAIN SCORE preoperatively and post operatively and for follow up period of until 1 year. Result: Mean value of all 12 patients preoperatively was 7.778 and postoperatively 2.0 and followed up for 1 year with VAS. A primary clinical success was said to be achieved when the patient had a relief of the Osteiod Osteoma type of pain at 24 h after the procedure. We had primary clinical success in all patients with no recurrence or any complication. Conclusion: RFA is a safe, simple and effective modality of treatment for OO with no complication and very high clinical success rate. We conclude that all osteoid osteomas should be treated by thermal ablation (radiofrequency/laser) rather than with surgical or percutaneous resection for better patient care and comfort.

OR 140

LIMB SALVAGE IN DISTAL TIBIAL OSTEOSARCOMA USING A CUSTOM MEGA PROSTHESIS

Introduction: Endoprosthesis for distal tibial malignancies incorporating the ankle joint has been a technically challenging procedure. We present the oncological and functional results of a series of distal tibial custom mega prosthesis in patients with distal tibial osteosarcoma. Method: Our series consists of 27 cases of distal tibial osteosarcoma treated with distal tibial custom mega prosthesis between 1994 and 2012. There were 17 males and 10 females with a mean age of 18 years (range 8 to 45 years). All the patients presented with stage II B osteosarcoma. A wide resection was done in 21 cases, marginal resection in five cases and intralesional excision in one case. Skeletal reconstruction was done using locally designed and manufactured custom-made distal tibial and ankle replacement prosthesis. The patients were followed up for a mean period of 112 months (range 204 to 12 months). Results: The mean functional score achieved according to the scoring system of the Musculoskeletal Tumor Society was 25.3/30 in 18 patients in whom the prosthesis remained in place. We encountered local recurrence in six patients out of which two underwent above knee amputation. Flap/skin necrosis and deep infection was seen in four cases and five patients had metastatic disease after surgery out of which four patients succumbed to the disease. Conclusions Limb salvage with prosthetic replacement is a viable treatment option in distal tibial osteosarcomas in carefully selected patients.

OR 141

Title L Role of immunohistochemistry in decision making for soft tissue sarcoma treatment

• Soft-tissue sarcomas are a rare and heterogeneous group of tumours, represent < 1 % of all adult malignancies. More than 60 % of soft-tissue sarcomas occur in the extremities making them the commonest site and trunk (19 %).

• Improvement in classification and diagnosis based on IHC have lead to the current idea that the specific histology is an important consideration when developing a treatment plan and may affect the prognosis

• The presence of a soft-tissue sarcoma in the extremity is no longer an indication for amputation. Function preserving alternatives for local control in these lesions are the norm without compromising on overall disease survival. Good functional and oncological results can be achieved with a combination of excision of the tumour and where required, suitable adjuvant therapies.

• Management requires multimodality approach with input from pathologists, surgeons, radiation oncologist, medical oncologist and .radiologist

• This article outlines the current understanding and emphasises the multimodality management of these challenging tumours based on IHC

• Our study included 69 patients presenting with soft tissue tumours of trunk and extremities to our department

• patients were worked up with biopsy/fnac, BMRI/CECT of the part, CXR, CECT chest .

• IHC was done in all case on biopsy and resected specimens based on which patients were subjected for further treatments

• 69 patients have undergone WLE

• All patients were followed for min 2 years with longest follow up of 6.5 years

• There were 21 recurrences

• CONCLUSION. IHC helps us to know the subtype of STS, its prognosis, adjuvant treatment and outcomes of treatment

OR 142

A retrospective clinicopathological study of 131 cases with endometrial cancers – Is it possible to define the role of retroperitoneal lymphadenectomy in low-resource settings?

Dr. Shiva kumar H. C_1, Dr. Bafna U.D_2, Dr. Vijayalaxmi Deshpande₃

1PG IN MCh[Surg Onco], KMIO, Room 210. PG Hostel, Bangalore-29, 919986618018, email; dr.hcshivkumar@gmail.com

Background: Endometrial carcinoma(EC),second most common gynecologic cancer worldwide. Management remain controversial. complete surgical staging may not necessary in patients with low-risk endometrial carcinoma, disease limited to the uterus without Grade 3 or deep myometrial invasion. Proper selection of low-risk patients problematic. In situations where there is limited pre and intraoperative assessment of high-risk factors, particularly radiographic imaging and frozen section assessment, the role of complete surgical staging may be beneficial. Aim: The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor grades, and their implications on lymph node metastasis. Material and methods: We conducted a retrospective descriptive study of 131 cases of endometrial cancer examined and treated at a tertiary regional cancer institute between the years 2003 and 2009. We reviewed the oncology database as well as the clinical records and surgico-pathological registry of all these patients. Results: The multiparity association with endometrial cancer was commonly seen 113/131(86.2 %). Twelve (9.7 %) patients preoperatively diagnosed as Grade 1 tumors upgraded to Grade 3 changes in postoperative specimens and six of these 12 patients (50 %) had lymph node metastasis. A total of 14/131(10.6 %) cases had lymph nodes metastasis. Conclusion: There is a poor correlation between the preoperative and the postoperative tumor grades. Routine pelvic lymphadenectomy may be a valuable method in low-risk cases and para-aortic lymphadenectomy may be limited to high-risk endometrial cancers. Key Words: Low-resource settings, myometrial invasion, parity, retroperitoneal lymphadenectomy, tumor grade

OR 143

Uterine Sarcoma: Clinicopathological Characteristics, Treatment and Outcome of the cases treated in Cancer Institute.

Raghunandan. G.C. Sridevi. V. Department of Surgical oncology, Cancer Institute(WIA), No. 18, Sardar Patel road, Guindy, Chennai - 600 036

Objective: To study the incidence, clinical characteristics, treatments and outcomes in patients with uterine sarcomas at Cancer Institute (WIA) Chennai. Methods: A medical record search of patients treated at Cancer Institute (WIA) Chennai was done from January 2000 to December 2013 for clinical characteristics and treatments. Results: Twenty nine uterine sarcomas were diagnosed during a 13-year period. The median age was 47 years (range 22–71). Abnormal bleeding was the most common presenting symptom (68.96 %). Only 27.58 % of the cases could be diagnosed preoperatively. Of 29 patients, 12(44.82 %) had leiomyosarcoma (LMS), 8(24.13 %) had carcinosarcoma, 8(30.76 %) had endometrial stromal sarcoma (ESS) and 1 (3.84 %) had smooth muscle tumor of uncertain malignant potential. The distribution by FIGO staging was as follows: stage I: 20 (68.96 %), stage II: 3(10.34 %), stage III: 3(10.34 %), and stage IV: 3 (10.34 %). The treatments were mainly hysterectomy with adjuvant radiotherapy. Conclusion: The incidence of uterine sarcoma at Cancer Institute (WIA) Chennai was around 1 to 2 % of uterine malignancies. The most common histologic type was leiomyosarcoma (44.82 %). The common presenting symptoms were uterine bleeding. In most cases, the treatment modality was surgery combined with Radiotherapy. Keywords: Endometrial stromal sarcoma; Leiomyosarcoma; Carcinosarcoma

OR 144

Clinicopathological study of 30 cases of Adult Granulosa cell tumor of ovary.

Dr. A. Arunandhichelvan, V. Sridevi, Dept of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, Email ID: drarun.tn@gmail.com

Aim: To evaluate the clinicopathological features of Granulosa cell tumors that were diagnosed and treated in a 12-year period. Methods: Thirty patients of Granulosa cell tumor treated from 2001 to 2012 in our institiute were studied. Data including demographics, stage, histologic types, surgery, chemotherapy, survival were collected from patient’s file and analysed. Results: Median age of presentation was 48 years (range 20–65). The common histologic subtypes included diffuse and mixed types. Most patients were diagnosed following an unplanned laparotomy for pain abdomen or excessive bleeding per vaginum. The most common complaint was abdominal pain in about 76 % of the patients. Only 11 (40 %) patients underwent primary staging without prior surgery elsewhere. Thirteen patients (46 %) underwent completion staging following an incomplete surgery done elsewhere. Of that 2 patients underwent fertility sparing surgery. Only 4 patients presented with advanced stage (IIIc/IV) and was treated with upfront chemotherapy. On histopathological examination of completion staging specimens in 13 patients, none had any evidence of residual disease, and there was no upstaging. Twenty-four (85 %) cases belonged to stage I. Adjuvant chemotherapy was administered for tumors more than 10 cm with or without capsule infiltration. No instance of synchronous / metachronous malignancies in uterus were noted. Serious complications related to chemotherapy were not noted. Conclusion: Granulosa cell tumours present mostly as early stage disease. They have a very indolent course and even the advanced diseases have a long survival with treatment. Size of the tumor and capsule involvement has been the major criteria to decide on chemotherapy in Stage I disease. The chemotherapy regimen has varied and evolved over years, still there is no regimen that is proven effective.

OR 145

LAPAROSCOPIC AND OPEN SURGICAL STAGING FOR ADENOCARCINOMA OF THE ENDOMETRIUM – AN ANALYSIS

Madhupriya. R.G.S. Sridevi. V. Department of Surgical oncology, Cancer Institute(WIA), No. 18, Sardar Patel road, Guindy, Chennai - 600 036

Objective:

1. To compare the patient, surgical, pathological and treatment characteristics of open and laparoscopic surgical staging for adenocarcinoma of the endometrium

2. To analyse the factors affecting the above outcomes after laparoscopic and open surgical staging for adenocarcinoma of the endometrium

Secondary Objective: To determine the Disease Free Survival (DFS) and Overall Survival (OS) after open and laparoscopic surgical staging for adenocarcinoma of the endometrium Methods: A retrospective analysis of all patients who presented with adenocarcinoma of the endometrium and treated surgically at the Cancer Institute (WIA) from the year 2006 to 2013 was done. Results: The median age of our study population was 55 years (Range 30-79 years) In our study the median BMI was higher in the laparoscopy group than in the open surgery group. The median hospital stay was significantly less in the laparoscopic staging group. The most common pathological stage was Stage I in both open and laparoscopic surgery group. Conclusion: The median age of our study population is about 8 years lower than that of the Western world. There is no statistically significant difference in the use of laparoscopy in patients with co-morbid conditions. Laparoscopic surgery results in significant reduction in hospital stay and incidence of complications especially surgical site infections and paralytic ileus. With time and experience the time for Laparoscopic staging is almost the same as that of open staging. There is significant decrease in the median blood loss compared to open surgery. The grade and stage distribution are comparable in the laparotomy and laparoscopy groups and the pelvic nodal yield is equal if not better in the latter group. There is also a trend towards improving nodal yield with the increasing surgical experience of the operating surgeon. Keywords: Endometrial adenocarcinoma; carcino-sarcomas

OR 146

CYSTOSARCOMA PHYLLODES: PATHOLOGICAL ENIGMA. Retrospective review of 162 cases.

Dr. Rajkumar. P.N., Dr. Vijaylakshmi Deshmane, Dr. Veerendra Kumar, Dr. M. Vijaya Kumar, Dr. Krishnamurthy. S, Department of surgical oncology, Kidwai Memorial Institute of Oncology, mail id - dr.rajpn@gmail.com

Aim- Phyllodes tumour (PT) is rare fibroepithelial neoplasm comprising < 1 % of all breast tumors. Clinical spectrum ranges from benign(B), borderline(BL) and locally recurrent type to malignant(M) and metastatic type. The aim of this study was to analyze clinicopathological factors, compare treatment options and evaluate outcome in patients with PT. Methods- We retrospectively reviewed 162 women with PT. The surgical intervention varied from simple excision (lumpectomy) / wide local excision (WLE) in benign cases to simple/modified radical or radical mastectomy (SM/MRM/RM) in malignant and recurrent tumours. Results- Out of 162 patients 95(58.64 %) were B, 29(18 %) BL and 38(23.45 %) were M. The mean age was 38 ± 8 years, ranging 18–75 years. Mean duration of lump was 28 ± 10 (2–64) months. The mean tumor size was 12 ± 5 (3–25) cm, of these 28 (17 %) had <5 cm, 81 (50 %) had 5–10 cm and 53 (33 %) had >10 cm. 92 (57 %) right, 67 (41 %) left and 3 (1.9 %) had bilateral PTs. No multifocal lesions were seen. Recurrence rates with lumpectomy (48.9 %) were higher compared to WLE (22 %), SM ((23.8 %), MRM/RM (14.2 %) (p = 0.004). Axillary lymph nodes were palpable in 12 patients (10 %) and on axillary dissection no positive lymph nodes were found. Malignant PT was seen in 24 % and distant metastasis in 7(18 %) patients. Mean duration of survival was 4 months. The median follow-up was 42 months and ranged 12–96 months. Conclusion- PT is pathological enigma. Till date no factors can accurately predict its recurrence and outcome. WLE with negative margins should be the initial surgery for all PT. PT is known for unpredictable behavior and high recurrence rates hence long term follow up is advised. Further research is warranted on molecular biology, receptor status and tumor markers.

OR 147

Treatment Outcomes After D2 Dissection In Operable Gastric Cancer – A Retrospective Analysis.

Background: Extent of nodal dissection in operable gastric cancers is still a debatable issue. While D1 dissection is considered adequate in many centers, D2 dissection has been the standard of care in specialized centers in India. The other important controversy in gastric cancer management is sequencing of chemotherapy (with or without radiotherapy) with surgery. Objective of this retrospective review is to find the long term outcome after D2 dissection (followed by postoperative adjuvant chemotherapy) done in a tertiary cancer hospital in India, to analyze surgical results and patterns of failure. Methods: A total of 112 gastric adenocarcinoma patients were taken up for surgery between 2003 and 2010(including Siewert type III GEJ lesions). Pre-surgery work up included endoscopic biopsy and CT scan of abdomen & thorax. Endoscopic ultrasound was done in only 14. Eight-two operable patients underwent gastrectomy with D2 nodal dissection. Distal gastrectomy was carried out for antral and pyloric lesions, total gastrectomy for body lesions and esophagogastrectomy for Siewert III GEJ lesions. Node positive patients received post surgery chemotherapy with ECF and patients with R1 resection (positive C/M) received radiotherapy (IMRT) in addition to chemotherapy. Information related to surgical details, complications, duration of hospital stay, histopathology, adjuvant treatment and treatment outcomes were retrospectively analyzed. Result: Out of 112 patients (79 male and 33 female with median age of 58.5) 71 had disease in distal stomach, 17 in body, 4 in fundus and 20 at GE junction. 30/112 (26 %) patients were found non resectable on laparoscopy prior to exploration, predominantly due to peritoneal disease. The analysis of pathological data of 82/112 resected patients revealed 7 patients had pT1 disease (8.5 %), pT2 = 17 (20 %), pT3 = 47 (57 %) and pT4 = 11 (13.5 %). Thirty-five percent patients had pN3 disease. Stage wise breakup of the resected patients revealed Stage I = 22 % StageII = 33 %, Stage III = 40 %, Stage IV = 5 %. Average nodal harvest was 29 (maximum = 80). 4/82 had a positive C/M and all of them received IMRT in addition to chemotherapy. All 4 suffered from local recurrence. PNI was recorded in 26/82 (31 %). Surgical mortality was zero and major morbidity 8 %. Median duration of hospitalization was 18 days. Regarding treatment outcome with a minimum duration of follow up of 3 years and a maximum of 10 years, 53/82 (64.6 %) are alive disease free. Correlation of failure pattern with TNM established, on univariate analysis, that increasing nodal burden increased the risk of local recurrence whereas increasing T stage predisposed to systemic spread. Both univariate and multivariate analysis of 26 PNI positive patients failed to establish any correlation of PNI as an independent risk factor for recurrence. Conclusion: D2 dissection with postoperative adjuvant chemotherapy is safe and effective for long term control, when done in specialized centres. Correlation of higher T stage with distant failure and higher N stage with local relapse, as indicated in this study, needs further assessment with more number of patients to gain statistical significance.

OR 148

HOW I DO IT: TOWARDS LEAK FREE ESOPHAGEAL SURGERY

Kannan N, Adarsh Kumar, Tyagi A, Talwar R.

Introduction: Esophageal surgery is perhaps the most formidable surgical procedure fraught with multitude of problems. If the surgical endeavour was not daunting enough the post operative phase beset with multiple problems is a challenge to any surgeon. Anastomotic leaks are perhaps the most discouraging of them all. Standardization of technique is essential for a teaching institution where surgery is performed by surgeons at different levels of competence an dexperience. Pathophysiology of Leak: Leak of the esophageal anastomosis is the result of interplay of multiple factors which are anatomical, vascular, treatment and technique related. How I do it: In our experience of 78 esophageal resections over 5 years we have used the tubularized gastric interponat with a major leak in 2 and minor subclinical leaks in 5 cases. We have used a thin 3 cm wide gastric tube based on the gastroeiploic artery with minimal handling at the pyloric end. The extent of terminal tube nourished by the submucosal plexus is reduced to bare minimum need. The terminal end of the tube is amputated to remove the least viable part to ensure there is a single anastomotic line for the end to end esophago gastric anastomosis. Anastomosis is done by a single layer of interrupted PDS suture in a tension free manner. Conclusion: Anasomotic technique and planning is important in prevention of anastomotic leaks in esophageal surgery to reduce the morbidity associated with this complication. Our technique has resulted in a low 3 % major leak and 8 % overall leak rate which is better than that often quoted in literature

OR 149

HYPERTHERMIC INTRATHORACIC CHEMOTHERAPY (HITHOC) FOR MALIGNANT PLEURAL MESOTHELIOMA

Dr. Prasanna G, Dr. Shabber S Zaveri, Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore

Aim: Malignant pleural mesothelioma is a rare cancer associated with asbestos exposure that has an increasing incidence. MPM arises from the pleural surface and tendency to invade adjacent organ or structures. Patient may die off loco regional tumor extension. MPM has poor prognosis, with a median survival of 6–12 months. Current treatment options are based on a multimodality regime involving chemotherapy, surgery and radiotherapy. Recently Hyperthermic chemotherapy perfusion techniques for the pleural mesotheliomas are developed, which might improve local control and the prognosis. We utilized this innovative technique in our patient & evaluated its feasibility. Case report: Our patient is a 58 years old gentleman with recent onset dyspnoea and right sided chest pain for 2 months. He was treated as pulmonary Kock’s with ATT and intercostal drainage. But he didn’t improve with 2 months of treatment. His PET-CT showed diffuse nodular thickening of the pleura on right hemithorax with hilar nodes. Thoracoscopy and biopsy done elsewhere showed malignant mesothelioma. We evaluated him further for resectabilty and his fitness for major resection. After informed consent he underwent posterolateral thorocotomy + right extrapleural pneumonectomy + mediastinal lymphadenectomy + right diaphragmatic resection + diaphragmatic reconstruction using PTFE mesh + HITHOC using cisplatin 260 mg in 3 l of dialysate fluid perfused in thoracic cavity at 41.5° centigrade over 90 min in open technique under general anesthesia. He was kept in ICU for observation for 2 days. He improved well in the ward. He developed Hypokalemia in the post operative period which was managed with I.V. and oral potassium. He was discharged on 10th POD. He has completed his adjuvant chemotherapy and is due for adjuvant radiotherapy. Brief procedure video will be shown in the oral presentation

OR 150

Prognostic value of metastatic lymph nodal ratio in Squamous cell carcinoma of Esophagus – A three step extrapolative study

Dr. Praveen Ravishankaran, Surgical Oncology Resident, Cancer Institute, Adyar, Chennai. Ph No: 9894125953, Email ID: preveen264@gmail.com

Aim: To explore the effectiveness of the ratio of positive lymph nodes to excised lymph nodes, namely the Metastatic Lymph Nodal Ratio (MLNR) as a prognostic factor in the survival of patients with carcinoma esophagus and to further extrapolated MLNR to the type of surgery performed (THE vs. TTE) in an attempt to predict the non-inferiority of one modality over the other. Methods: Retrospective review of the operated esophageal cancer patients treated at a tertiary cancer centre in South India between January 2002 and December 2006 was done. The inclusions criteria for the present study were histologically confirmed squamous cell carcinoma of the thoracic esophagus, patients who underwent upfront surgery (Either TTE with three field lymphadenectomy or THE) with an R0 resection. The patients were classified into three revised nodal categories: pN0(MLNR = 0), pN1(MLNR = >0 to </= 0.1), and pN2(MLNR >0.1). Statistical analysis was done with help of SPSS version 17 software (SPSS Inc., Chicago, IL). Results: The survival difference was statistically significant between the three MLNR subgroups(p = 0.038). On head to head comparison between TTE and THE, the survival of patients was not statistically significant (p = 0.742). In the TTE subgroup, the survival difference was statistically significant between the three MLNR subgroups (p = 0.000).In the ‘THE’ subgroup, again the survival difference was statistically significant between the three subgroups (p = 0.006). For the MLNR pN0 subgroup, TTE had a better survival outcome than that of ‘THE’ (p = 0.030). For the MLNRpN1 subgroup ‘THE’ had a better survival than that of ‘TTE’ (p = 0.045). For the MLNRpN2 group the survival difference between the two subgroups was not statistically significant (p = 0.846). Conclusion: The overall survival of patients with squamous cell carcinoma of the esophagus can be discriminated based on 3 groups: MLNR = 0, MLNR </= 0.1 and MLNR >0.1 and is a reliable prognostic indicator. Although the overall survival for patients undergoing TTE or ‘THE’ for the entire cohort of patients was not statistically significant, the exploratory analysis however did demonstrate the superiority of TTE over ‘THE’ in the node negative patient cohort (MLNR = 0) as well as the non-inferiority of ‘THE’ over TTE in node positive patient cohort. (MLNR </= 0.1 and MLNR >0.1) It is however important that the decision regarding the approach to surgery for each patient must be individualised taking into account all the parameters that can possibly impact the final outcome.

OR 151

VIDEO ASSISTED THORACOSCOPIC MOBILISATION (VATS) FOR THORACIC ESOPHAGEAL CANCERS -TECHNICAL ASPECTS AND LOGISTICS REVIEWED- SINGLE INSTITUTION

Ajay Chanakya. V ¹, Ganesh M.S², Sriphani. P³, Uday. K⁴, Amritha. P⁵,Sangi Reddy. N⁶, Vasu Reddy. C⁷., Department of Surgical Oncology, Vydehi institute of medical sciences, #82, EPIP area, Whitefield, Bengaluru-560066.

Aim: The purpose of this retrospective study is to analyze and share the effectiveness of using VATS for resection of thoracic esophagus with regards to issues like ease of mobilization, circumferential marginclearance, nodal clearance, operative time and post-operative morbidity and recovery. Methods: A retrospective study was performed over last 6 months at our centre in a small group of eight patients who had operable thoracic oesophageal lesion. A standard three or four port thoracoscopic approach through right chest was employed in all cases. Criterion for eligibility included lesions primarily in mid and lower thorax which were resectable on imaging. All patients underwent total mobilisation with a thoracoscope. The gastric conduit was fashioned through a laparoscope /laparotomy. Varying degrees of lymphnodal clearancewas carried out depending on various patient factors Results: Of 8 patients 5 were female and 3 were male. Average duration of procedure was 60 min (Range: 50–70 min) which is equivalent or less than open thoracotomy. Average number of nodal harvest was 12 nodes(Range 6–18). Circumferential resection margin was negative in all patients and one patient had mucosal margin positivity at proximal end due to skip lesion. Postoperative complication of chyle leak from abdomen, unrelated to VATS, noted in one patient. Average period of postoperative stay was 8 days (Range: 7–10 days). Conclusion: VATS is a practical and effective alternative to open thoracotomy. Better magnification and reach to inaccessible areas in thorax leads to ease in achieving better mobilization. Good lymphnodal clearance can be easily achieved through VATS. Reduction of operative time is significant. Significantly lower chest complications were noted.

OR 152

Comparison between different modalities in the treatment of squamous cell carcinoma of the esophagus

Dr. Praveen Ravishankaran, Surgical Oncology Resident, Cancer Institute, Adyar, Chennai. Phone No: 9894125953, Email ID: praveen264@gmail.com

Background and Aim: The 5-year overall survival for patients treated with a curative intent in carcinoma esophagus is < 30 %. As the overall survival is dismal with most strategies, the ideal treatment approach remains controversial. This deficit has been augmented with the lack of well-conducted prospective randomized controlled studies which has further fuelled this controversy. During the last decade, neoadjuvant treatment with chemotherapy and chemo-radiation has evolved and has challenged surgery as the primary modality of treatment. Given the lack of conclusive proof, a well conducted retrospective analysis may provide some meaning conclusion. Methods: A retrospective study of patients who were treated at our hospital for carinoma esophagus between the years 2002 and 2006 was done. The total number of patients who were diagnosed to have biopsy proven esophageal cancer during the study period was 555. Case records of all these patients were analysed, and all patients who underwent either a transthoracic esophagectomy with three field lymphadenectomy (3F TTE),transthoracic esophagectomy with two field lymphadenectomy (2F TTE) or transhiatal esophagectomy (THE), and those who received concurrent chemoradiation(CTRT) with curative intent were included in the study. Only patients with squamous cell carcinoma of the middle and lower third of the esophagus were included in the study. Statistical analysis was done with help of SPSS version 17 software (SPSS Inc., Chicago, IL). Results: The 5-year disease free survival was 47, 48, 40 and 22 % in patients in the 3F TTE, 2F TTE, THE, and CTRT groups respectively. The 5-year disease free survival for the entire surgical cohort (3F TTE, 2F TTE and THE) and Chemo-radiation were 45 and 22 % respectively, which does not reach statistical significance (p = 0.087). There was no statistically significant difference in disease free survival between the various treatment groups, though there was a trend towards improved loco-regional control with extended nodal dissection. The 5-year overall survival was 51, 46, 40 and 28 % in patients in the 3F TTE, 2F TTE, THE, and CTRT groups respectively. The 5-year overall survival for the entire surgical cohort (3F TTE, 2F TTE and THE) and CTRT were 47 and 28 % respectively, which was statistically significant, (p = 0.038) however the difference in survivals between the surgical arms was not statistically significant. Conclusion: The overall survival in the surgical arm in our study fared better than the CTRT arm. In the absence of well controlled randomized trials, it would be prudent to conclude that every treatment modality has its own place in the treatment of carcinoma esophagus and further the treatment rendered must be individualized and acceptable for each patient.

OR153

A Case Study Of Nasopharyngeal Carcinoma

Aim: Aim of the study is to discuss a young female 17 years age suffering from Nasopharyngeal carcinoma. Method: A patient Miss. X, Female, Age 17 came to the Oto-Rhino Laryngology and Head and Neck Surgery department, Aarupadai Veedu Medical College and Hospital, Pondicherry – 607402, with the complaints of 1. Neck Swelling both side, 2. Ear pain, and 3. Difficulty in swallwing for the past 9 months.

• On Examination - Throat. Trismus present.

• Nose. Normal

• Both Ears. Normal Tympanic membrane intact.

• Neck. 4 × 3 cm in size, nodular surface, firm in consistancy and non tender swelling present in the left side of neck exdending to the posterior triangle. 4 × 2.5 cm in size, nodular surface, firm in consistancy and non tender swelling present in the right side upper part of neck.

  Patient is known mentally challenged.

  CT Scan Neck, Nasal Endoscopic examination, and Tru-Cut Biopsy done.

Results:

1. CT Scan Neck. 6.5 × 4.2 × 3.8 cm size ill defined soft tissue mass is seen in the parapharyngeal, retropharyngeal space on the left side. 4 × 3.5 × 3 cm size ill defined soft tissue mass is seen inferiorly to the above described lesion on the right side.

2. Nasal Endoscopic examination under Local Aneasthesia. A reddish mass seen in the nasopharynx.

3. Tru-Cut Biopsy - both side swelling. Impression- Matastatic deposits of poorly differentiated carcinoma in the lymphnode.

Conclusion: Usually malignant tumours are more common in old age. But the incidence of Nasopharyngeal carcinoma below the age of 30 is 2 % of all the tumours of head and neck. Nasopharyngeal carcinoma is the most confusing one and generally it is misdiagnosed easily.

OR 154

MANAGEMENT OF SINO NASAL TERATOCARCINOSARCOMA A RARE CASE REPORT WITH REVIEW OF LITERATURE

Shameena shinaz, Dept of Ent, Head and neck surgery

Sri Ramachandra Medical College, E- MAIL ID- shameenaaziz@hotmail.com

Aim- To present a rare case of sino nasal teratocarcinoma which is an unusual clinical entity in Otolaryngology practice. Methods- Here we profile a 43-year old female patient who presented with unprovoked epistaxis from the right nostril. After complete evaluation and necessary multi modality management (surgery and chemo radiation), she is on a constant follow up. Results- This patient is already 7 years post operative follow up and is being subjected to periodic PET scanning. Conclusion-The rarity of this pathology and the successful multi modality treatment protocol with a very meticulous follow up regimen makes her clinical case unique. Histopathological diagnosis being very rare and interesting, its association with morbidity and mortality is very well established in literature scan. Although the 5 years survival is not very encouraging (40–50 %), here is a patient who has bucked the trend with a good treatment protocol.

OR155

UNUSUAL PRESENTATIONS OF PAPILLARY CARCINOMA OF THYROID - THE OTOLARYNGOLOGIST’S PERSPECTIVE

Sanjeev Mohanty, Dept of Ent, Head and Neck Surgery

Sri Ramachandra Medical College, E- MAIL ID drsanjeevmohanty@gmail.com

Aim - To present a series of patients diagnosed as Papillary carcinoma of thyroid with varied presentations including some rare clinical encounters in Otolaryngology practice. Methods - Here we profile a retrospective study of a sample size of 56 patients over a period of 5 years with papillary carcinoma of thyroid with multiple variants. All these patients were diagnosed and treated in the general otolaryngology clinic of a tertiary care Medical College hospital. The clinical presentation, symptom complex, quantum of disease, investigation profile, and treatment modalities were analysed. Results - All the patients in the study were subjected to surgical management and the spectrum of surgery ranged from total thyroidectomy to completion thyroidectomy along with neck dissection, tracheostomy, parapharygeal space tumour clearance, medialization thyroplasty etc. Most of the patients had good results on post operative follow up with reduced morbidity. Conclusion – Papillary carcinoma of thyroid is a known clinical entity and the treatment protocol is well established. Patients usually present with solitary nodule, multiple nodules or diffuse thyroid enlargement with change of voice and respiratory embarrassment. However, some uncommon clinical presentations like dysphagia, aspiration, foreign body sensation in throat and masquerading within an underlying thyroglossal tract cyst should also be borne in mind when dealing with such a pathology. The statistical increase in the number of cases of late should alert the clinician especially the practicing otolaryngologist to be well informed of such clinical variants.

OR 156

TOTAL LARYNGO PHARYNGO OESOPHAGECTOMY WITH GASTRIC TRANSPOSITION – A BOON OR A BANE

Dr. Mukundan Subramanian, Dept of Ent, Head and Neck Surgery, Sri Ramachandra Medical College, E- MAIL ID docmukundan@gmail.com

Instruduction: AIM - To present a series of 3 patients who underwent TPLO (total laryngo pharyngo oesophagectomy with gastric transposition) for post cricoid malignancy in the tertiary care referral institute. Methods - A retrospective study of three patients who underwent total laryngo pharyngo oesophagectomy with gastric transposition over the past 2 years was done. All these patients were diagnosed with post cricoid malignancy. All these patients were diagnosed with and treated in the general otolaryngologic clinic and the treatment options were debated in the tumour board before embarking on the definitive palliative surgery. All patients were initially diagnosed and treated for iron deficiency anaemia and were on regular follow up before the biopsy of the cricopharyngeal web confirmed squamous cell carcinoma. Results – Quality of life issues associated with this highly morbid surgical procedure and the overall prognostic values are assessed and analysed from the otolaryngologist’s point of view. The management protocol and the options of palliation in the form of surgery or chemo radiation is a subject of discussion Conclusion – Although total laryngo pharyngo oesophagectomy is an established surgical procedure for palliation in diagnosed cases of squamous cell carcinoma of the post cricoid region it is still controversial. The overall morbidity and mortality along with the quality of life issues needs to be considered by the otolaryngologist, before subjecting the already moribund patient to such morbid procedure.

OR 157

Evaluation of Photodynamic therapy in advanced head and neck cancers

Col N Kannan, Brig B N Kapur, Maj Richa Joshi

Introduction: Head and neck cancers account for nearly 50 % of cancers seen in India. The cancer has high propensity of recurrence in the local site. Photodynamic therapy (PDT) is a less explored option in management of recurrent head and neck cancers AIMS AND OBJECTIVES: To evaluate tumor response, duration of response, toxicity of therapy and improvement of quality of life with PDT in advanced recurrent head and neck cancers Material and methods: 61 patients were included in this study. Twenty-five patients were suitable for and received PDT using mTHPC (Foscan®) as the photosensitizing agent. Thirty-six patient received standard chemotherapy. Patients were followed-up monthly for a period of 12 months. Results: 14 of the 25 patients had complete response(CR) with single dose PDT, 7 needed second dose and 4 needed multiple doses.. Also, 7 out of those requiring multiple doses had residual lesion and needed additional chemotherapy. On follow up 14 of those who showed CR, none had recurrence. Of those requiring multiple doses 6 were recurrence free, 1 had local recurrence managed by excision, none had disease progression. No deaths were observed. In the chemotherapy arm, 4 had complete response, 26 showed partial response, rest showed disease progression. Only 12 patients could complete follow up for 12 months. Six had no disease at primary site and 6 had progression. Acute side effects were more in the PDT arm. Responders of both arms showed improvement in quality of life parameters. The patients who had PDT had longer periods of response. Conclusions: Photodynamic therapy is an effective curative option in the treatment of advanced recurrent head and neck cancers.

OR 158

Medullary carcinoma thyroid – experience of a tertiary cancer centre.

Praveen Ravishankaran, Surgical Oncology Resident, Cancer Institute, Adyar, Chennai, Email ID: preveen264@gmail.com

Aim: Controversies remain regarding the optimal surgical management of MTC, which includes the extent of cervical lymph node dissection. Adjuvant radiation therapy, chemotherapy and radioiodine therapy have doubtful benefits. In this study we have tried to figure out the demographic details of medullary carcinoma thyroid in this part of the world and to answer a few questions pertaining to the management of this disease like metastatic lymph nodal ratio as a prognostic marker, post-operative irradiation in node positive disease, hypercalcitoninemia in post operative setting, DMSA scan as a reliable test for detecting recurrence, factors affecting overall survival, thus comprehensively encompassing many facets of management of this fascinating condition. Methods: This is a retrospective review of 53 patients with proven MTC, who presented to our institution over a period 28 years from 1985 to 2012. A detailed analysis of the patients demographics, pre-operative and post-operative variables namely staging, investigations, complications, recurrence rates, metastatic lymph nodal ratio, post operative calcitonin status, post operative irradiation, and the effectiveness of DMSA scan were analysed. Results: Metastatic lymph nodal ratio was not found to be a significant predictor of disease free survival (p = 0.625). The patients who received post operative radiotherapy for N1b disease (i.e. patients with positive lateral neck nodes) had a better median survival(86.6 months) when compared to the group that did not receive irradiation for proven nodal metastasis(21.4 months), reaching statistical significance (p = 0.05). The median survival of the subgroups with or without postoperative hypercalcitoninemia were 72 months and 27 months respectively and the 10 years disease free survival was also statistically significant (p = 0.04). In our study, DMSA scanning had a sensitivity of 75 % and specificity of 56 % in detecting recurrance in patients with elevated serum calcitonin levels. In our cohort of patients the 5 and 10 years overall survival is 56 and 34 % respectively and the 5 and 10 years disease free survival in our cohort is 93 and 80 % respectively. Conclusion: Among the various variables analysed post operative hypercalitoninemia, addition of post operative irradiation in nodal positive patients and the presence of distant metastasis closely correlated with the survival of the patients. Medullary carcinoma thyroid is a constantly evolving disease with many new innovations happening by the hour. It is prudent to stay abreast with the latest management guidelines for appropriate treatment of this fascinating cancer.

OR 159

PMMC Patch pharyngoplasty reconstruction after laryngectomy – our experience at a regional cancer institute

Kamal Kishor Lakhera ¹MS, Ashok M shenoy² MS, ¹ Department of surgical oncology, ² Department of head and neck oncology, Kidwai memorial institute of oncology, Bangalore

Aim- To evaluate our results of post laryngectomy pharyngeal defect reconstruction by Pectoralis Major Myocutaneous Flap in respect to pharyngocutaneous fistula and post operative rehabilitation of patients. Methods- retrospective analysis of 48 patients who underwent wild field laryngectomy and PMMC patch pharyngeal reconstruction from year 2009 to 2013 was done. Patient and tumor characteristics were noted, CT scan and histopathology reports were reviewed. Incidence of pharyngocutaneous fistula calculated and its correlation with various factors was established. Follow up records were evaluated. Results- 43 (89.6 %) patients were male. Total 15 (31.2 %) patients developed pharyngocutaneous fistula. Twelve (80 %) patients were managed by conservative treatment and 3 (20 %) patients required surgical management. There was 1 (2 %) post operative mortality. Factors associated with increased fistula rate were, tumor volume >50 ml, tumor involving > 1/3 of hypopharyngeal length, lower situated tumor and after salvage surgery. Post surgery rehabilitation in respect to swallowing and tolerance to radiotherapy was satisfactory in most patients. Conclusion- Many reconstructive options are available for pharyngeal defect closure after laryngectomy ranging from various locoregional flaps to free flaps. The ideal method for reconstruction should have the following attributes if possible: high success rate of tissue transfer, low donor site morbidity, low fistula and stenosis rates, restoration of the ability to swallow, and tolerance of postoperative radiotherapy. We found that PMMC patch pharnygoplasty is a reliable option for pharyngeal reconstruction and our pharyngocutaneous fistula rate was comparable to world literature available. Various patients and tumor variables were associated with increased fistula rate that may predict the risk preoperatively.

OR 160

Assessing Patient Reported Outcome in Recurrent/ Metastatic head and neck cancer by utilizing modification of Vanderbilt Head and Neck Symptom Survey

Ashutosh Chauhan, K P Sheshadri, Malignant Disease Treatment Center, Command Hospital(CC), Lucknow,bolubonkey@rediffmail.com

Aim: Vanderbilt Head and Neck Symptom Survey is a tool which focus on symptom burden in patients due to acute and late effects of primary therapy. However, it does not include symptom burden specific to recurrent / metastatic head and neck cancers. We describe a modification to VHNSS wherein 15 additional questions developed and test them on cases of recurrent/metastatic head and neck cancers Methods: A prospective study of 01 year duration which enrolled cases of recurrent/metastatic head and neck cancers. VHNSS Ver 2.0 along with 15 additional questions were administered. These Additional questions include: diet change due to mouth swelling; tongue movement affecting speech/swallowing; swelling of face/neck; bad breath; drooling; wound complications: drainage/pain/odor; nasal congestion/drainage; eyes watering; numbness of face/tongue/ear/scalp; headaches and confusion.;perception of burden to family/friends; lost independence; embarrassment; mood swings; stress. The tool was administered in person during outpatient visit by the patient Results: 56 patients enrolled in the study. All Patients found the questionnaire readable and understandable.. A full range of scores was noted for all questions of VHNSS and 12 out of 15 additional questions. Overall, symptom burden was reported moderate to severe symptoms (VHNSS ≥5) >45 % of patients for 45/50 questions of original VHNSS. However, 62 % reported severe symptom burden when additional 15 questions were asked (≥7). Conclusions: Symptom burden experienced by patients with RMHNC are often different than at initial presentation and during primary treatment. The original VHNSS is inadequate. The 15 novel questions could aid in improved palliation to these patients.

Sleeve Resection of trachea with primary end to end anastomosis for invasive well differentiated thyroid cancers- single centre experience in 10 years

Background: Transmural invasion of the trachea either by infiltration or by direct invasion by well-differentiated thyroid carcinomas is a marker of more aggressive tumor behavior with high risk of recurrence and cause death due to respiratory obstruction. Segmental resection of the trachea with primary end to end anastomosis may lead to better locoregional control improving the survival in thyroid cancer patients with tracheal invasion. Materials and Methods: A retrospective analysis of 7 patients (n = 7) who underwent segmental tracheal resection and primary end to end anastomosis in invasive well differentiated thyroid cancers between May 2005 and April 2014 were included in the study. Four patients (57.1 %) were male and 3 patients (42.8 %) were female with the mean age of 64.8 years. Two patients with recurrent thyroid cancers had vocal cord palsy preoperatively (one unilateral and the other bilateral vocal cord palsy). Four patients (57.1 %) underwent tracheal resection with primary end to end anastomosis along with total thyroidectomy and central lymph node dissection while the other 3 (42.8 %) patients underwent the same procedure for tracheal invasion with completion thyroidectomy for recurrent thyroid cancers. Laryngeal drop aided by Montgomery suprahyoid release was done in 4 cases (57.1 %) to gain sufficient length of trachea for anastomosis after resection and Intraoperative chin stitch was placed in all the patients. Result: All 7 patients survived with minimal post operative complications and the mean hospital stay was 11 ± 8 days. Two patients (28.6 %) had anastomotic leaks which settled conservatively. Endotracheal tube was kept in situ for 3 days for one patient who had bilateral vocal cord palsy with post operative stridor. No patients needed tracheostomy or dilatation post operatively. All patients had papillary carcinoma thyroid with tracheal invasion in histopathology. Five patients on regular follow up are free of disease with suppressive dose of thyroxine. One patient lost follow up and other died due to bilateral lung metastasis. Conclusion: Patients with mucosal invasion of the trachea by well-differentiated thyroid carcinomas should be treated by surgical resection followed by primary reconstruction whenever technically feasible with trained expertise. It is a safe life saving procedure with very low morbidity and mortality leading to improved survival.

OR 161

Title: Bipaddled Pectoralis Major Myocutaneous Flap versus Double flap for the reconstruction of advanced oral cavity defects – Single centre experience in 10 years

Ajay chandrasekar VS¹, Prof. R. Rajaraman², Dr. Subbiah shanmugam³

Background: Reconstruction of mucosal and skin defects after composite resection for advanced oral cavity cancers is still a major challenge. Though the defects are reconstructed with pectoralis major myocutaneous flap (PMMC) and deltopectoral flap (DP) traditionally, presently the preferred method of reconstruction is microsurgical technique. But due to lack of infrastructure and expertise, most centres still prefer local or regional flaps. We compare the use of Bipaddled PMMC flap with double flap for the reconstruction of skin and mucosal defects after resection in advanced oral cavity cancers in terms of operating time, duration of hospital stay, complications, aesthetic outcome, donor site morbidity and psychosocial issues. Materials and methods: Study design: Retrospective analysis from the oral cancer database from March 2007 to May 2014. Eighteen patients who underwent bipaddled PMMC flap reconstruction (n = 18) (Arm-A) and 15 patients who underwent double flap reconstruction (n = 15) (Arm-B) for mucosal and skin defects in advanced oral cavity malignancy were included in the study. Donor site in the chest was primarily closed in both Arm-A & Arm-B and DP donor site was reconstructed with split skin graft in Arm-B. Results: In Arm-A, 12 patients were male and 6 patients were female with a mean age of 43.8 years. Average size of bipaddled PMMC flap ranged from 8 × 6 to 12 × 10 cms which was bipaddled based on the size of skin and the mucosal defect. In Arm-B, 14 patients underwent PMMC with DP flap reconstruction and 1 patient underwent PMMC + Forehead flap reconstruction. Mean hospital stay was 14 ± 5 days for Arm- A and 24 ± 3 in Arm-B. Mean operating time for Arm-A was 258 ± 24 and 296 ± 37 min for arm B. Eight out of eighteen (44.4 %) patients had minor complications like marginal necrosis, wound infection and flap oedema which were conservatively managed in Arm-A while 8 patients (44.4 %) had no complications. One female patient had total flap loss (5.6 %) and another female patient had differential flap loss (5.6 %) which was reconstructed with deltopectoral flap. In Arm-B, 7 out of 15 patients (46.7 %) had minor complications and 7 other patients had no complications (46.7 %) and one patient had partial loss (6.7 %) of deltopectoral flap. Median follow up is from 1 month to 8 years. Comparing with Arm-B, Arm-A had significantly reduced operating time (p < 0.001), reduced hospital stay (p = 0.001) and far acceptable aesthetic outcome with minimal psychosocial issues. The difference in the complication rates in both arms was not statistically significant (p = 0.999). Donor site morbidity was higher in Arm-B with more psychosocial issues compared to Arm-A. Conclusion: The simplicity, reliability and the versatile nature with a good aesthetic outcome makes the

OR 162

REDEFINING THE PRE-OPERATIVE DIAGNOSIS OF CARCINOMA THYROID.A clinical, pathological and radiological co-relation.

K Shankar¹, SP Nayak², C Srinivas², Krishnamurthy³, Veerandra Kumar^3, Kidwai Memorial Institute of Oncology, Bangalore.

Aim: Fine Needle Aspiration Cytology(FNAC) is considered the gold standard diagnostic test for thyroid cancer. Ultrasound of the neck is the next most common, easily available investigation performed in thyroid cancer. This study aims at testing the diagnostic accuracy of these preoperative investigations by correlating them with the final histopathological diagnosis. Material and Methods: This is a single institution retrospective study of 258 patients with thyroid swellings that were treated between MAY 2012 and May 2014. All the patients underwent FNAC and Ultrasound of the neck besides the routine investigations prior to surgery. The demographic, clinical, pathological and radiological data was tabulated and analysed using proportion tests and chi square tests wherever sufficient numbers were available for statistical interpretation. Results: Of the 258 cases, the female: male ratio was 1: 0.2 with a mean age of 42.3 years. One forty-three cases were reported as malignant (Papillary carcinoma of the thyroid PTC 88 %). Of the remaining 115 cases 92 were Bethesda II/III/IV (60 %/20 %/18 %). These patients underwent a hemi thyroidectomy and were followed up depending on the final Histopathological report. Of these 60 % turned out to be Malignant (PTC 60 %) on final histopathological report and were thus subjected to a second surgery (Completion thyroidectomy). The presence of hypoechogenicity and micro calcification in these swelling on preoperative ultrasound were found to be statistically significant in predicting their risk for malignancy. (p < 0.001) The presence of a cystic nodule with micro calcification, internal vascularity, hypoechogenicity was highly predictive of being malignant. (100 %). INFERENCE: FNAC reports read in the light of the ultrasound findings will help us diagnose malignant thyroid tumours. We recommend that those patients whose thyroid nodules have micro calcification, internal vascularity, hypoechogenicity on ultrasound undergo hemithyroidectomy with frozen section in order to identify papillary carcinoma.

OR163

Central compartment dissection in papillary carcinoma thyroid.

Dr. Vishnu Kurpad, Dr. Sandeep P Nayak, Dr. C Srinivas, Dr. M VIjayakumar

Introduction: Papillary ca thyroid is the most common thyroid malignancy. Metastatic disease to regional lymph nodes (LNs) is common in papillary thyroid carcinoma (PTC). LN dissection is increasingly performed as part of the surgical management of PTC. The role of prophylactic central neck dissection (pCND) in PTC is unclear. The central compartment is considered to be the first echelon of nodal metastasis in thyroid cancer. Theoretically, removal of central LNs may alter the prognosis of thyroid cancer especially in PTC. Despite the excellent prognosis, many patients with PTC will develop nodal metastases in the central neck (level VI) or lateral neck (levels II, III, and IV) at the time of presentation or during the course of follow-up. Aims and Objectives: To assess the lymph node yield and the number of positive nodes in central compartment neck node dissections, the incidence of post operative hypocalcemia, recurrent laryngeal nerve palsy and hospital stay. Materials and methods: We compared 20 consecutive patients who underwent total thyroidectomy with a therapeutic central compartment neck node dissection to patients who underwent total or completion thyroidectomy from 2013 to 2014 at our Institute. Results: The mean lymph node yield was 7.9 .with 3.15 showing metastasis in patients who underwent central compartment neck node dissection. The mean post op serum calcium level was 7.23 as compared to 8.6. Post op stay was 6-7 days in the neck dissection group and 4-5 days in the total thyroidectomy group. Transient hypocalcemia was reported in 2 patients. None of the patients had irreversible damage to both RLN in both the groups. One patient underwent emergency tracheostomy in the TT group. Conclusions: Although the authors of previous studies quoted high rates of hypoparathyroidism as well as recurrent laryngeal nerve injury, more recent data has demonstrated that central neck lymph node dissections can be done with minimal morbidity. From our experience we feel that central compartment neck node dissection in papillary carcinoma thyroid is a safe procedure in experienced hands in high volume centers with minimal morbidity and mortality.

OR164

Correlation of Body Image and Depression in patients of head and neck cancer.

Ashutosh Chauhan, KP Seshadri, Malignant Disease Treatment Center, Command Hospital(CC), Lucknow email: bolubonkey@rediffmail.com

Aim: To study the relationship between body image and depression symptoms in patients who have been treated for head and neck cancer. Methods: A prospective, longitudinal analysis. Body image and depressive symptoms were measured in patients diagnosed with head and neck cancer and treated for the same at baseline, end of treatment, 6 weeks post-treatment, 12 weeks post-treatment, 24 weeks post treatment. Results: 58 individuals diagnosed with head and neck cancer were included in this study. Forty-one were male and 17 were female. Participants ranged from age 36 to 69 years (Mean 53.2+/− 10.5). At 24 weeks post-treatment, body image scores were statistically significantly higher than they were at the end of treatment (p = 0.016); 6 weeks post-treatment (p = 0.032). and 12 weeks (p = 0.041) Depressive symptoms were observed to be significantly high at the end of treatment (p < 0.001) and 6 weeks post-treatment (p = 0.036) with a return to baseline by the 12-week post-treatment assessment (p = 0.115). Body image and depressive symptoms were statistically significantly associated at 6 weeks post-treatment, 12 weeks post-treatment and 24 weeks post treatment (r _s −0.32 to −0.56, p < 0.05). Conclusions: This study supports the association between poorer body image and increased depressive symptoms. Increased depressive symptoms can be the cause of symptom cluster typically noticed by patients of head and neck cancer.

OR165

Association of Human Pailloma Virus and squmous cell carcinoma of oral cavity; in Indian scenario.

Aims: To look for the prevalence of Human Papilloma Virus (HPV) in patients with squamous cell carcinoma of oral cavity (OSCC). Method: A biopsy was taken from all cases of suspected malignant ulcers of oral cavity under local anaesthesia for histopathological and microbiological analysis. Having confirmed the lesion as SCC, the HPV testing for HPV 16 and 18 was carried out on those frozen samples in the microbiology laboratory by PCR technique. Results: The most common site of OSCC was tongue in 50 % cases followed by buccal mucosa in 30 % cases. About 80 % patients in the study had addiction to either tobacco or alcohol or both. The results for HPV were positive in only 2 patients (4 %) which wasn’t significant. Recurrence was seen in 18 % patients during the study period. Among them one was HPV positive, the rest being HPV negative. Conclusion: Head and neck cancer is one of the common cancers in India, associated with major morbidity and mortality.

OR166

Predictive factors of morbidity after salvage surgery in Head and neck cancers

Gaurav Goel, Rahul Buggaveti, Shawn T Joseph, Krishnakumar Thankappan, Subramania Iyer. Dept of Head and Neck Surgery. Amrita Institute of Medical sciences, Kochi, India.

Aim- To determine predictors of morbidity after salvage surgery of recurrent head and neck cancer and to evaluate Survival outcomes of salvage surgery. Methods- Retrospective analysis of 154 pts who underwent salvage surgery after chemo radiation and surgery between August 2004 and May 2011 are included. Patient, tumor and treatment factors, complications, tube dependence and recurrence patterns are analyzed. Wound complications included analysis of bleeding, local infection, pharyngo cutaneous fistula and oro cutaneous fistula. Partial and total flap loss, re exploration data recorded. Feeding tube and tracheostomy tube dependence is analyzed. Results- Most of pts in this series has oral cancer(70) and laryngeal cancer(31). One hundred twelve pts received previous RT, 47 received CTRT and 38 are treated with surgery alone. Forty-four pts are treated with salvage of both primary and neck, 73 with salvage of primary and 33 with salvage of neck alone. Recurrent T stage T4a-47(31 %), T3-17(11 %). Recurrent N stage N2b 21(14 %), N2a 9(6 %). Free flap reconstruction is done in 54 (36 %) pts. Wound complications are seen in 28 % of pts, flap complications in 12 % and tube dependence in 44 %of pts. Mean duration of hospital stay is 13 days and ICU is 3.4 days. Previous RT (p = 0.018), previous CT (0.021) and type of salvage surgery (p = 0.002) are significant in univariate analysis for wound complications. In multivariate analysis type of salvage surgery is significant (p = 0.011, ORR-2.751, CI 1.264–5.981). Type of salvage surgery is significant in univariate analysis for flap complications (p = 0.040) and tube dependence (p = 0.006). Two years post salvage overall survival is 48.7 % and 2 year disease free survival is 45 %. Conclusion-Salvage surgery has resulted in good survival outcomes. Previous RT, previous chemotherapy and type of salvage surgery are significant predictors for wound complications. In salvage cases, combining primary surgery with neck surgery will result in significant increase in morbidity.

OR 167

SHAPE MODIFIED RADIAL FOREARM FLAP FOR SIMULTANEOUS RECONSTRUCTION OF ORAL CANCER AND SUBMUCOUS FIBROSIS

Shreya Bhattacharya, Vidhyadharan Sivakumar, Krishnakumar Thankappan, Subramania Iyer,¹ Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala

Aim Oral cancer in association with submucous fibrosis is a common clinical scenario. Double free flaps have been adopted in most of the precedent reports. In an attempt to simplify the procedure, a new technique using a single shape modified radial forearm flap (RFF) is introduced. Methods This technique was applied in 3 patients of oral cancer with severe trismus. The procedure consisted of (1) cancer resection (2) intra-oral release of bilateral buccal and palatal fibrotic tissue (3) coronoidectomy (4) reconstruction with shape modified RFF with proximal and distal skin paddles for bilateral buccal defects and bridging segment for the palate. Results Pre-operative mouth opening was 2–8 mm (mean 5 mm). The mean total flap length was 12 cm with 4 cm of bridging segment. The mean skin paddle size for the cancer defect was 6.5 × 3.5 and 2.5 × 4 cm for the contralateral side. Two flaps survived uneventfully. Venous thrombosis was noted in 1 flap, which was successfully salvaged. One patient needed flap revision due to excessive bulkiness. The post-operative mouth opening was 15–35 mm (mean 25 mm) after a follow-up of 12 months and the mean increase was 20 mm. All donor sites were grafted. Conclusion A shape modified RFF, using a single donor site and one microsurgery, is an useful option for simultaneous repair of complex defects in oral cancer and SMF.

OR168

Is Human Papilloma virus positive and negative Oral Cancer behaves differently among tobacco abusers

Akhtar Naseem, Kumar Vijay, Misra Sanjeev, Gupta Sameer, Deptt. of Surgical Oncology, King George’s Medical University (K.G.M.U.), Lucknow, India, Email ID – naseemakhtar97@gmail.com

Introduction Oral squamous cell carcinoma (OSCC) is one of the most prevalent malignancy in India and Tobacco and alcohol are major etiological factors. Human Papilloma Virus is increasingly being reported to be associated with OSCC with different incidence rate that varies geographically. Purpose We aimed to evaluate influence of Human Papilloma virus status on oral cancer patients among tobacco abusers. Results/ Conclusion Study group included 232 histologically proven cases of OSCC consuming some form of tobacco. HPV detection was done by 13 High Risk HPV Real Time PCR Kit on Real Time PCR in biopsy samples. HPV presence was confirmed in 20/232 (8.62 %) OSCC cases. Mean age for HPV positive cases was 51.5 years and for HPV negative cases was 48.2 years. HPV positivity was more prevalent among females. Recurrence was more common in HPV positive tumours. But survival was more in HPV positive patients.