Predictors of toxicity after neoadjuvant chemoradiotherapy for locally advanced gall bladder cancer

Background

The present study evaluated the correlation of hepatobiliary toxicity and radiation dose received in patients undergoing neoadjuvant chemoradiotherapy (NACRT) for locally advanced unresectable gall bladder cancers (LAGBC).

Methods

Twenty-six patients with LAGBC, treated with NACRT (55-57 Gy/25 fractions/5 weeks and weekly gemcitabine 300 mg/m²) within a phase II study, were included. Whenever feasible, surgery was performed after NACRT. Acute and late hepatobiliary toxicity was recorded. Treatment scans were retrieved to delineate central porto-hepatobiliary system (CPHBS), resected liver surface, segment IV B and V, and duodenum. The doses received by these structures were recorded and correlated with toxicity.

Results

Of 26 patients, 20 (77%) had partial or complete response and 12 (46%) had R0 resection. At the median follow-up of 38 months, overall survival was 38%. Eight (30%) patients had post-treatment toxicity, of which most common was biliary toxicity (30%). A correlation was observed between the biliary leak and V45Gy CPHBS >50 cm³ (P = 0.070). Higher toxicity was observed in those with metallic stents (P = 0.072).

Conclusion

The incidence of the biliary leak was 46%. CPHBS dose was found to correlate with biliary leaks. Restricting V45Gy CPHBS <50 cm³ and using plastic stent may facilitate a reduction in hepatobiliary toxicity in patients undergoing NACRT and surgery.

Is resection for noncolorectal, nonneuroendocrine liver metastases justified?

INTRODUCTION

The role of hepatectomy in non-colorectal, nonneuroendocrine liver metastasis (NCNN) is not clearly defined. This study represents a step towards surgical frame-shift as an integral part of treatment pathway in these heterogeneous, arbitrarily treated tumors. It aims to provide answers regarding favorable tumor types and patient profiles for which liver metastasectomy would prove beneficial.

MATERIALS AND METHODS

Retrospective analysis of prospectively maintained database of hepatectomy in NCNN liver metastasis.

RESULTS

A total of 50 patients out of 516 patients underwent liver resection during this period. In 27 patients, the liver metastases presented synchronously whereas the other 23 were metachronous. Median disease-free interval (DFI) was 36 months. Gastrointestinal stromal tumors (GIST) were the most common type of primary malignancy (15, 30%). In 41 patients, the liver was the only site of metastases. At a median follow-up of 32.5 months, 24 patients developed recurrences. Five-year overall (OS) and disease-free survival (DFS) for the entire cohort was 60% and 32%, respectively. Median OS was highest in the breast (93 months) followed by GIST (56 months). Patients with longer DFI showed improved OS. (p = .04).

CONCLUSION

Liver resection for NCNN metastases is safe and feasible in selected patients with good survival outcomes. Longer DFI correlates with better survival.

Primary retroperitoneal GIST: Case report and review of literature

Extraintestinal gastrointestinal stromal tumors (EGISTs) are mesenchymal tumor with no connection to tubular gastrointestinal system. They commonly arise from omentum and mesentry. Retroperitoneum is a rare primary site. We herein report a case of a 33 year old woman who underwent upfront surgery for primary retroperitoneal gastrointestinal stromal tumor and is now disease-free on adjuvant Imatinib.

A Validation Study of Liver Volumetry Estimation by a Semiautomated Software in Patients Undergoing Hepatic Resections

Purpose The purpose of this study was to validate the use of a semiautomated software for liver volumetry preoperatively by comparing it with the volume of resected specimen in patients undergoing hepatic resections.

Materials and Methods This is a single-center retrospective study of patients who underwent estimation of future liver remnant (FLR) using Myrian XP-Liver which is a semiautomated software for hepatectomy. The estimated resection volume, which is the sum of volume of normal liver to be resected and tumor volume, was compared with actual specimen weight to calculate the accuracy of the software. The statistical analysis was performed with SPSS software version 24.

Results Data on FLR estimation using the semiautomated software was available for 200 out of 388 patients who underwent formal hepatic resections. The median resected volume of surgical specimen was 650 mL (interquartile range [IQR] 364–950), while the median estimated volume using the Myrian software was 617 mL (IQR 362–979). There was significant correlation between estimated resection volume calculated using the semiautomated method and actual specimen weight (p-value < 0.0001) with the Spearman’s correlation value of 0.956.

Conclusion The estimated volume of liver to be resected as calculated by the semiautomated software was accurate and correlated significantly with the volume of resected specimen, and hence, the estimation of FLR volume may likely correlate with the true postoperative residual liver volume. In addition, the software-based liver segmentation, FLR estimation, and color-coded three-dimensional images provide a clear road map to the surgeon to facilitate safe resection.

Mustard oil consumption, cooking method, diet and gallbladder cancer risk in high- and low-risk regions of India

The current study aimed to investigate the role of cooking with mustard oil and other dietary factors in relation to gallbladder cancer (GBC) in high- and low-incidence regions of India. A case-control study was conducted including 1,170 histologically confirmed cases and 2,525 group-matched visitor controls from the largest cancer hospital in India. Dietary data were collected through a food frequency questionnaire. For oil consumption, we enquired about monthly consumption of 11 different types of cooking oil per family and the number of individuals usually sharing the meal to estimate per-individual consumption of oil. Information about method of cooking was also requested. Odds ratios (ORs) and 95% confidence intervals (CIs) quantifying the association of GBC risk consumption of different types of oil, method of cooking, and dietary food items, were estimated using logistic regression models, after adjusting for potential confounders. High consumption of mustard oil was associated with GBC risk in both high- and low-risk regions (OR = 1.33, 95% CI = 0.99-1.78; OR = 3.01, 95% CI = 1.66-5.45), respectively. An increased risk of GBC was observed with deep frying of fresh fish in mustard oil (OR = 1.57, 95% CI = 0.99-2.47, p-value = 0.052). A protective association was observed with consumption of leafy vegetables, fruits, onion and garlic. No association was observed between consumption of meat, spicy food, turmeric, pulses or with any other oil as a cooking medium. The effect of high consumption of mustard oil on GBC risk, if confirmed, has implications for the primary prevention of GBC, via a reduced consumption.

Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy

BACKGROUND

Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots.

METHODS

A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020.

FINDINGS

Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV - VI).Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in <60 years (P = 0.169). The median hospital stay was 1 to 9 days across specialties.Postoperatively, 26 patients were tested for COVID 19 and 6 tested positive. They all had higher grade surgeries but none required escalated or intensive care treatment related to COVID infection.

INTERPRETATION

A combination of scientific and administrative rationale contributed to favorable outcomes after major elective cancer surgeries. These results support the continuation of elective major cancer surgery in regions with Covid 19 trends similar to India.

Immunoglobulin G4-related cholecystitis mimicking a locally advanced gallbladder cancer-a case report and review of literature

Immunoglobulin G4 (IgG4)-related disease is a multi-organ immune-mediated condition that can mimic many inflammatory, malignant, and infectious disorders. Isolated IgG4-related cholecystitis without systemic manifestation is extremely rare. We report a rare case of IgG4-related disease with its clinical, radiological and histopathological findings involving only the gallbladder which presented initially as unresectable locally advanced gallbladder cancer on imaging but was diagnosed as IgG4-related cholecystitis preoperatively depending upon serum IgG4 levels and immunohistochemistry. Patient was successfully treated with steroids followed by simple cholecystectomy in view of symptomatic gallstones. Preoperative diagnosis is challenging for IgG4-related cholecystitis in view of mass like appearance of the lesion with surrounding invasion on imaging so most of the cases are reported postoperatively. Knowledge of this disease as differential for malignancy can save patients from extensive resections in view of its steroid responsive nature. Xanthogranulomatous cholecystitis mimicking gallbladder cancer can coexist with this disease.

Retroperitoneal Sarcomas: Prognostic Factors and Outcomes of a Series of Patients Treated at a Single Institution

Retroperitoneal sarcomas (RPS) are rare heterogeneous tumors arising in the retroperitoneum with unique biological and behavioral patterns that are thought to be closely linked to histology. The aim of the study was to audit our results and analyze various clinico-pathological factors including surgical excision, histology, and their implications on the recurrences and survival outcomes in RPS. Retrospective analysis of patients treated at a tertiary referral center in India from March 2008 to July 2017 was performed. The clinico-pathological variables were analyzed for their association with tumor recurrence and survival with special emphasis on histological subtype. The primary outcome was overall survival (OS). One hundred consecutive patients operated for RPS were analyzed. Of these, 27 were operated for recurrent tumors. Liposarcomas (LPS) and leiomyosarcomas (LMS) constituted 50% (n = 50) and 30% (n = 30) of patients respectively. Complete tumor excision was achieved in 83%, with 43% patients undergoing adjacent organ resection. At a median follow-up of 25.3 months, the median disease-free survival (DFS) and overall survival (OS) were 30 months and 87.8 months respectively. On multivariate analysis, tumor grade was the only factor to significantly affect survival (p = 0.001 for DFS and 0.005 for OS). There was no difference in survival outcomes between infiltrative and adhesive tumors with respect to adjacent organ invasion (p = 0.361 for OS). Tumor grade remains an important prognostic factor affecting disease-free and overall survival in retroperitoneal sarcomas irrespective of tumor size, site, and histology.

THU0540 A PHASE 2B STUDY OF INTRAVENOUSLY (IV) ADMINISTERED TC 99M TILMANOCEPT TO DETERMINE DIFFERENTIAL UPTAKE, REPRODUCIBILITY OVER TIME AND IMAGE STABILITY IN HEALTHY SUBJECTS AND IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA) ON STABLE TREATMENT

Background:

At present, there are no reliable noninvasive means to directly monitor disease activity in RA patients. Activated macrophages are a critical component of the inflammatory etiology of RA due to their role in prolonged RA joint inflammation and destruction through the release of pro-inflammatory cytokines and chemokines. Tc 99m tilmanocept is a radiopharmaceutical imaging agent that binds with high affinity to the macrophage mannose receptor CD206 that resides on activated macrophages. Previous clinical trials demonstrated safety and tolerability of Tc 99m tilmanocept, as well as a determination of optimal clinical dose and timeframe for RA imaging.

Objectives:

The current phase 2b study aims to evaluate reproducibility and stability of imaging and will assess quantitative Tc 99m tilmanocept uptake cut points that reliably enable discrimination between joints of healthy people and RA patients.

Methods:

The analysis cohort contained 18 healthy controls (HC) clinically free of inflammatory joint disease and 12 subjects with clinically diagnosed RA who are on stable anti-inflammatory and/or anti-rheumatic therapy. Each subject received a 150-mcg dose of tilmanocept radiolabeled with 10 mCi of Tc 99m in a 3mL IV injection. Injection was followed by planar imaging at 60 and 180 minutes for both HC and RA subjects on study Day 0 and repeated in RA subjects on Day 8. Images were quantitatively assessed to detect localization within synovial spaces of bilateral hands and wrists by determining average pixel intensity in each region of interest relative to average pixel intensity in a joint-specific reference region.

Results:

Data obtained from the interim analysis support the hypothesis that Tc 99m tilmanocept imaging can provide robust quantitative imaging in HC and RA subjects. Repeat images within and between days demonstrate root mean squared differences that are approximately 10% or less of the observed localization of Tc 99m tilmanocept. Qualitatively, images of HC indicated no disease-related site-specific localization, whereas localization is present in RA subjects at levels expected given the difference in macrophage number and density in different pathotypes of RA. Notably, images from patients with active RA exhibit the same localization patterns on images taken in a test-retest fashion on the same day as well as in subjects with images acquired on Day 0 and Day 8 (see Figure 1). These results show low imaging readout variability, enabling reliable quantification of joints with RA-involved macrophage-mediated inflammation. Analysis of the HC and RA images was used to determine initial quantitative “cut-points” to differentiate between joints with and without the inflammation typically seen in RA.

Figure 1.

Tilmanocept consistently localizes in areas of macrophage-driven inflammation, demonstrating low variability. RA patients exhibit reproducible localization over a 1-week period. Typical of healthy subjects, no evidence of inflammation-related Tc 99m tilmanocept uptake was observed in the healthy control. Images on the right show same patient imaged on 2 different days.

Conclusion:

Tc 99m tilmanocept imaging of the joints in healthy subjects as well as in patients with active RA under stable treatment is reproducible and stable over time. The results confirmed that the signal in joints of healthy subjects and RA patients can be quantified and used to establish cut points to distinguish inflamed and non-inflamed joints on a joint-by-joint basis. These results provide the foundation for a noninvasive, objective method to monitor activity in macrophage-driven inflammation in joints of patients with RA.

Disclosure of Interests:

Ayah Hussein Employee of: Currently employed by Navidea Biopharmaceuticals, David Ralph Consultant of: Previous consultant for Navidea Biopharmaceuticals, Employee of: Currently employed by Navidea Biopharmaceuticals, Beth Potter Employee of: Currently employed by Navidea Biopharmaceuticals, Bonnie Abbruzzese Employee of: Currently employed by Navidea Biopharmaceuticals, Rachael Hershey Employee of: Currently employed by Navidea Biopharmaceuticals, Katherine Repp Employee of: Previously employed by Navidea Biopharmaceuticals, Haya Shakhtra Employee of: Currently employed by Navidea Biopharmaceuticals, Mehak Goel Employee of: Currently employed by Navidea Biopharmaceuticals, Madison Palmer Employee of: Currently employed by Navidea Biopharmaceuticals, Allison Kissling Employee of: Previously employed by Navidea Biopharmaceuticals, Carley Hartings Employee of: Previously employed by Navidea Biopharmaceuticals, Michael Blue Employee of: Currently employed by Navidea Biopharmaceuticals, Michael Rosol Employee of: Currently employed by Navidea Biopharmaceuticals

Pathologic Doppelgänger: Thyroid-like intrahepatic cholangiocarcinoma with synchronous primary thyroid carcinoma in a young woman

Intrahepatic cholangiocarcinoma (ICC) accounts for 8-10% of all malignant liver tumors. Preponderance for elderly males and occurrence of varied morphological patterns in ICC is well known. Recent reports have described a newly recognized variant of thyroid-like cholangiocarcinoma. Herein, we present a hitherto unreported synchronous occurrence of an intrahepatic thyroid-like cholangiocarcinoma and a separate thyroid carcinoma in a 23-year-old post-partum woman. Both tumors displayed striking resemblance to follicular variant of papillary thyroid carcinoma (FVPTC) however exhibited disparate immunohistochemical profiles: the intrahepatic tumor was positive for CK7 and CK19, and negative for TTF-1, PAX-8 and thyroglobulin whereas, the thyroid tumor was positive for TTF-1, thyroglobulin and PAX-8. Young age, female proclivity, large mass at presentation and unique histology in thyroid-like ICC hint towards a distinctive subset of ICC. Awareness and recognition of this rare entity is essential, not only for accurate diagnosis, but also for gathering information on its biology and clinical behavior. Synchronous occurrence with a FVPTC is a challenging scenario that can simulate metastatic disease and mislead subsequent patient management. Whether morphologic similarity points to an underlying linkage between the two different tumors needs exploration.

Role of positron emission tomography-contrast enhanced computed tomography in locally advanced gallbladder cancer

INTRODUCTION

This study aims to define the role of flurodeoxyglucose (^18F -FDG) positron emission tomography-contrast enhanced computed tomography (PETCECT) scan in upstaging disease in patients with locally advanced gallbladder cancer (LAGBC).

METHODS

An analysis of a prospectively maintained database of gallbladder cancer (GBC) patients was performed. Patients found to have locally advanced (T3 and/or T4 or N+) but non-metastatic disease on initial imaging, either a contrast enhanced computed tomography (CECT) or a magnetic resonance imaging (MRI) scan, underwent an additional PETCECT for staging and the results impacting treatment decision were recorded.

RESULTS

One hundred and three patients of LAGBC underwent CECT/MRI and PETCECT. 48/103 (46.6%) were found to be upstaged to stage IV after PETCECT. The most common metastatic site was non-regional retroperitoneal lymph nodes (12 patients, 11.7%) followed by satellite lesions in liver (11, 10.7%). Fourteen (13.6%) patients had equivocal findings on PET scan that required confirmation by tissue sampling out of which 10 (71.4%) were subsequently found to have metastatic disease. The only statistically significant factor predicting distant spread on PETCECT was the presence of loco-regional nodes on CT scan (odds ratio 6.15, P = .006).

CONCLUSION

PETCECT is a valuable tool to rule out metastatic disease in patients presenting with LAGBC.

Primary hepatic neuroendocrine tumours of liver- a rarity: Single centre analysis of 13 patients

Backgrounds/Aims

Primary hepatic neuroendocrine tumours (PHNETs) are a rarity and this rarity imparts management complexities.

Methods

A retrospective analysis of prospectively maintained liver database from 2009 to 2018 was performed and patients with PHNETs were identified and studied for clinical, imaging and pathological features, surgical outcomes, disease free and overall survival.

Results

Thirteen patients of PHNET were identified following rigorous investigational protocols, which constituted 0.6% of all liver tumours (2095) in our series. The median age of patients was 50 years (14–65), with male to female ratio of 9:4. Eight patients (62%) underwent hepatic resections as primary treatment, while 5 (38%) patients received peptide receptor radiotherapy, trans-arterial chemotherapy, trans-arterial radiotherapy or a combination of these. In the surgical group at a median follow up of 36 months (range 5–114 months), 4 (50%) patients were alive without disease and disease free survival was 20 months. Median OS in surgical group was 47 months (40–53, 95% confidence interval) that was better but not statistically significant from that of non-surgical treatment group (36 months).

Conclusions

PHNETs are rare tumours that require multidisciplinary treatment approach. Liver directed surgery centred management leads to better clinical outcomes in these selected patients.

Hepatocellular carcinoma metastasis to the buccal mucosa masquerading as oral cavity malignancy: Case report of a rare entity

Hepatocellular carcinoma, a disease of the developing world, is known to present with extrahepatic metastases. Most common site being the lungs, it is not uncommon for metastases to present at unusual sites like the rectum, spleen and the diaphragm, among others. Metastases to the oral cavity is rare, with the most common primaries being lung, breast and the kidney. Metastases of a hepatocellular carcinoma to the oral cavity is a rare entity with extremely limited data in literature. We present one such unique case of oral cavity metastases from a hepatocellular carcinoma who presented to the Division of Head and Neck Oncology services of our hospital with a large oral cavity lesion, on subsequent workup of which, a hepatocellular carcinoma was identified. Awareness of this possibility can aid in accurate diagnosis and early management of a condition associated with an advanced stage at presentation and poorer prognosis.

Comparison of treatment plans feasible through AI enabled multidisciplinary online tumor board solution versus NCCN-based clinical decision support system (CDSS)

816

Background: Multidisciplinary tumor boards at Academic Medical Centers (AMC) maximize cancer outcomes. Guidelines based CDSS are alternatives to determine care pathways. Since 2015, 300 AMC cancer experts in USA and India use an AI enabled online tumor board solution, “NAVYA,” to scale low cost access to multidisciplinary expertise, on 1-2 minutes of expert time per decision (ASCO 2017). Methods: GI patients who used NAVYA between 5/1/15-8/31/19 were analyzed. Actionable treatment plans generated by NAVYA were compared to NCCN. Actionable treatment plans include chemotherapy protocols (doses, frequencies), radiation protocols (sites, fractions), etc. Inactionable specialty level decisions (CT-RT vs. surgery) lack specificity. Results: 1302 patients (4638 treatment decisions) were analyzed: 61% (794) male, 80% between age 45 to 75, mostly with Colon, Pancreas, Gallbladder, Rectum, or Stomach cancer; 49.7% non-metastatic. Cohort was comparable to GLOBOCAN estimates. In 82.2% (3812/4638) decisions, NAVYA added value beyond NCCN. First, in 4.5% (212/4638), NAVYA recommended a patient-specific treatment plan that was not part of NCCN. Second, in 3.2% (148/4638), NAVYA recommended treatments plan for clinical scenarios not covered by NCCN, (for eg. 3rd line therapies). Third, in 74.5% (3452/4638), NAVYA used patient specific criteria including resource constraints and patient preference to choose a treatment plan amongst the multiple pathways provided by NCCN and added actionable treatment details. Conclusions: Guideline based CDSS are insufficient to make the vast majority of actionable treatment decisions. Scaling rapid access to multidisciplinary experts is critical. Leapfrogging existing guidelines based CDSS, NAVYA online tumor board makes actionable expert treatment plans possible at a large scale.

Outcome of Robot-Assisted Radical Cholecystectomy in a High-Volume Tertiary Cancer Center in India

Introduction: Minimally invasive radical cholecystectomy is a complex laparoscopy. Robotic surgery is now an option to complete a radical cholecystectomy because of its high definition, magnified three-dimensional view of the operative field, and articulating instrumentation.^1–3 Robotic surgery enables a safe dissection in otherwise difficult to access areas such as the porta hepatis. This video reviews the role of robotic surgery in the management of gall bladder (GB) malignancy.

Methods: A 28-year-old lady, with no comorbidities, presented with abdominal pain and underwent an evaluation with a contrast-enhanced CT scan of chest and abdomen. The CT scan revealed a mass in the GB with no evidence of distant metastases. Liver function tests were normal and a CA19-9 was 898 U/mL. A robotic radical cholecystectomy using five ports (four robotic and one assistant port) was performed. The procedure started by clearing the hepatoduodenal ligament nodes (stations 8, 12, and 13 with interaortocaval node sampling). The triangle of Calot was then dissected and secured with clips. Next a wide excision of segments 4b and 5 was performed including the GB. The complete specimen was extracted in a bag from a small incision at the assistant port.

Results: The procedure was performed in 330 minutes with a blood loss of 200 mL. There were no perioperative complications and the postoperative stay was 3 days. Final histopathology report revealed moderately differentiated adenocarcinoma of GB invading serosa (pT3) with negative margins and 4 out of 14 lymph nodes showed presence of metastases. The overall cohort shows 22 robotic radical cholecystectomies for GB malignancy. The median age was 53 years. The average duration of surgery was 270 minutes with a median blood loss of 120 mL. The median postoperative stay was 4 days and the median nodal yield for radical cholecystectomy was 8. The overall median survival at 18 months was 100% with one recurrent hepatic lesion.

Discussion: Robotic radical cholecystectomy may offer technical superiority over laparoscopic surgery and is an oncologically acceptable approach with good short-term oncologic outcomes. This type of surgery may require a highly specialized center with adequate experience in hepatopancreatobiliary surgery.

No competing financial interests exist.

Runtime of video: 9 mins 5 secs

Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer

Purpose

The rapidly increasing burden of cancer in India has profound impacts on health care costs for patients and their families. High out-of-pocket (OOP) expenditure, lack of insurance, and low government expenditure create a vicious cycle, leading to household impoverishment. Complex cancer surgery is now increasingly important for emerging countries; however, little is understood about the macro- and microeconomics of these procedures. After the Lancet Oncology Commission on Global Cancer Surgery, we evaluated the OOP expenditure for patients undergoing pancreatico-duodenectomy (PD) at a government tertiary cancer center in India.

Methods

Prospective data from 98 patients who underwent PD between January 2014 and June 2015 were collected and analyzed. The time frame for consideration of expenses, including all preoperative investigations, was from the first hospital visit to the day of discharge. Catastrophic expenditure was calculated by assessing the percentage of households in which OOP health payments exceeded 10% of the total household income.

Results

The mean expenditure for PD by patients was Rs.295,679.57 (US$74,420, purchasing power parity corrected). This amount was significantly higher among those admitted to a private ward and those with complications. Only 29.6% of the patients had insurance coverage. A total of 76.5% of the sample incurred catastrophic expenditure, and 38% of those with insurance underwent financial catastrophe compared with 93% of those without insurance. The percentage of patients facing catastrophic impact was highest among those in semiprivate wards, at 86.7%, followed by those in public and private wards.

Conclusion

The cost of PD is high and is often unaffordable for a majority of India’s population. A review of insurance coverage policies for better coverage must be considered.

Performance of Hong Kong Liver Cancer staging system in patients of hepatocellular carcinoma treated with surgical resection: An Indian validation study

BACKGROUND

Hong Kong Liver Cancer staging (HKLCS) system lacks external validation.

AIMS AND METHODS

We conducted a study to validate the prognostic and clinical utility of HKLCS system in the patients with hepatocellular carcinoma (HCC) of heterogeneous etiologies treated with hepatic resection with curative intent at Tata Memorial Centre, Mumbai, India.

RESULTS

A total of 144 patients underwent resection for HCC. Our patient cohort was comparable to the original developmental cohort in median age and gender distribution but differed in etiology, liver function status, and tumor venous invasion. On Kaplan-Meier survival curve analysis for overall and disease-free survival, we could achieve statistically significant separation of curves in both Barcelona Clinic Liver Cancer staging (BCLCS) and HKLCS staging systems (P < .000). Interstage discrimination between early and intermediate stages for survival was higher in HKLCS system (P value of .039 vs .091). The area under the receiver operating characteristic curve for the survival of BCLCS and HKLCS systems for the entire patient population was 0.66 and 0.60, respectively, which was not statistically significant (P = .31).

CONCLUSION

The HKLCS system offered higher interstage discrimination power in the patients with HCC treated with resection and may be equally applicable to nonalcoholic steatosis-related chronic liver disease and noncirrhotic patient population.

Stereotactic body radio therapy for inoperable large hepatocellular cancers: results from a clinical audit

OBJECTIVES

To evaluate the outcomes of stereotactic radiotherapy (SBRT) in the treatment of inoperable hepatocellular carcinomas (HCC) that are unsuitable for, or refractory to other liver-directed therapies.

METHODS

Between March 2015 and June 2018, patients with primary HCCs refractory to or unsuitable for treatment with other liver-directed therapies were treated with SBRT. Patients of Child status A5-B7 and with normal liver reserve ≥ 700 cc were preferred. Local control (LC), overall survival (OS), progression free survival (PFS) and effect of prognostic factors were analysed.

RESULTS

21 patients with inoperable HCCs were treated. The median tumour diameter was 9.6 cm (5-21) and median tumour volume was 350 cc (32.9 - 2541). The median SBRT dose prescription was 42 Gy/6 fractions (25 - 54 Gy/6#). The 1- and 2-year LC rate was 88 and 43 % respectively. Overall rate of > grade III toxicity was 14 %. Patients with Child A5 liver function had a better median OS than A6 and B7 patients [21 vs 11 vs 8 months]. Also, tumours with GTV < 350 cc volumes had a better OS compared to GTV of greater than 350 cc [24 months vs 8 months, p value = 0.004].

CONCLUSIONS

This study showed that SBRT can be used safely and effectively to treat inoperable HCCs with or without prior loco-regional therapies, resulting in good local control and survival with acceptable toxicity.

ADVANCES IN KNOWLEDGE

Use of SBRT in inoperable HCC is safe and effective.

Neuroendocrine Carcinoma of Gallbladder: A Step Beyond Palliative Therapy, Experience of 25 Cases

PURPOSE

Published literature on gall bladder neuroendocrine tumors (GB NETs) is limited with none reporting the role of multimodal therapy.

METHODS

Patients with histologically confirmed GB NETs treated at Tata Memorial Hospital, Mumbai, from January 2010 to June 2017 were analyzed. Staging was done by contrast-enhanced computed tomography (CECT) of abdomen and chest or a positron emission topography (PET) scan. Tumor marker (CA19-9) was measured. WHO-2017 guideline was used to classify GB NETs. GB NETs were categorized as early disease (ED) (T1, T2, N0, i.e., stages I and II); locally advanced disease (LAD) (T3, T4, or N+, i.e., stage III); and metastatic disease (MD). Response to treatment was assessed with RECIST1.1 criteria.

RESULTS

Twenty-five patients of GB NETs were identified; 19 with neuroendocrine carcinomas (NECs) and 6 with mixed adenoneuroendocrine carcinomas (MANECs). Two patients (8%) presented with ED, 9 (36%) with LAD, and 14 (56%) had MD. Those with ED underwent open revision radical cholecystectomy. Both received adjuvant chemotherapy (ACT) with six cycles of carboplatin-etoposide and were disease-free at 3 months of follow-up. Of the nine patients with LAD, six received three cycles of neoadjuvant chemotherapy (NACT) (carboplatin-etoposide) and three operated upfront. All six patients showed partial response to NACT and five underwent open radical cholecystectomy with R0 resection. All patients operated after NACT received three cycles of ACT. Their median follow-up was 7 months (range 3-22 months). Three patients with LAD developed metastasis after median disease-free survival of 5 months. The median survival in patients with MD was 12 (range 6-23) months.

CONCLUSIONS

In carefully selected patients of GB NECs, downsizing with NACT facilitates radical resection with negative margins.