Immunotherapy with nivolumab after progression on lenvatinib in advanced hepatocellular carcinoma: A real-world Indian experience

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Background: Firstline treatment of advanced hepatocellular carcinoma (HCC) till recently has been sorafenib or lenvatinib. Lenvatinib, due to its better tolerability and efficacy (in PFS) over sorafenib, is our preferred first line treatment. Nivolumab, with an objective response rate (ORR) of 14.3% and median duration of response of 16.6 months, was approved by FDA on the basis of the CheckMate-040 trial in patients who progressed or were intolerant to sorafenib. There is very limited data of immunotherapy on progression with lenvatinib. Methods: This is a single center, retrospective analysis of patients with advanced HCC who progressed on first line lenvatinib and received treatment with nivolumab. The endpoints were objective response rate (ORR), progression free survival (PFS), overall survival (OS) and toxicity. Results: 15 patients who progressed on lenvatinib, received nivolumab at 3 mg/kg, 2 weekly as second line therapy between July 2019 to July 2021. There were 2 females and 13 males. Median age was 66 years (37-77 years). All patients were BCLC stage C. AFP was elevated in 11 patients. Child Pugh score was A in 10 patients, and B in 5 patients. 7 patients had background of hepatitis B and 1 had hepatitis C. The number of cycles of nivolumab ranged from 2 to 13 cycles. 3 patients (20%) had partial response, 2 had stable disease and 10 (66.6%) had progressive disease by recist criteria. The ORR was 20% and median PFS was 3 months. Median OS was 8 months. The common side effects were hypothyroidism in 7 (46.6%), fatigue in 4 (26.6%) and skin rashes in 3 (20%) patients. Conclusions: Immunotherapy with nivolumab showed limited efficacy in our patients of HCC who have progressed on lenvatinib. There were few patients who showed durable response, but there are no biomarkers to choose these patients. The immune related side effects were manageable. With the first line approval of combination therapy with atezolizumab and bevacizumab, single agent second line immunotherapy with its limited efficacy, may have a reduced role in HCC management.

Combination of immunotherapy and tyrosine kinase inhibitor in first-line metastatic renal cell carcinoma: A real-world Indian experience

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Background: Immuno-oncology (IO) agents in combination with oral tyrosine kinase inhibitors (TKIs) has become a standard first line therapy in metastatic renal cell carcinoma (mRCC) patients. Various combinations such as pembrolizumab + axitinib, avelumab + axitinib, nivolumab + cabozantinib and pembrolizumab + lenvatinib have all shown better results than sunitinib. There is very limited data about this from India. Methods: This is a single center, retrospective study of mRCC patients, who received first line treatment was nivolumab or pembrolizumab with axitinib or lenvatinib. The endpoints were objective response rate (ORR), progression free survival (PFS), overall survival (OS) and adverse events (AE). Results: Between Jan 2019 to Jan 2021, 22 patients were treated with IO + TKI combination. 12 patients received axitinib, and 10 lenvatinib. Age range was 35 to 78 years with 18 males and 4 females. IMDC risk stratification showed 3 favorable (13.6%), 13 intermediate (59%) and 6 poor risk (27.2%) patients. 2 patients (9%) achieved complete response(CR), 13 (59%) partial response (PR), 4 (18.2%) had stable disease and 3 (13.6%) progressed. The ORR was 68%. Median PFS was 22 months (1 month- 24 months). OS at 1 year was 92%, and median OS was not reached. Grade 3/4 immune related adverse events (AEs) were seen in 3 (14.2%) patients (1 colitis,1 pneumonitis,1 encephalitis), for whom the IO was discontinued. TKI related grade 3/4 AEs were seen in 8 patients (38%), and were managed with dose reductions. Conclusions: Combination IO + TKI is a very effective first line therapy in mRCC. An ORR of 68%, median PFS of 22 months and 1 year OS of 92% is the best we have seen in our patients. The efficacy of this combination is seen in all IMDC subgroups. The combination is well tolerated, and the TKI AEs are comfortably managed with dose reduction. IO combinations should be preferred over single agent TKIs (sunitinib or pazopanib) as first line therapy.

A comparison of outcomes following total and selective peritonectomy performed at the time of interval cytoreductive surgery for advanced serous epithelial ovarian, fallopian tube and primary peritoneal cancer - A study by INDEPSO

OBJECTIVES

To compare clinical outcomes following total and selective peritonectomy performed during interval cytoreductive surgery (CRS) for stage IIIC/IVA serous epithelial ovarian cancer.

METHODS

In this retrospective study, extent of peritonectomy was classified as total parietal peritonectomy (TPP) which comprised of removal of the entire parietal peritoneum and the greater and lesser omenta or selective parietal peritonectomy (SPP) that included 1/>1 of parietal peritonectomies performed to resect sites of residual disease. A comparison of patient and disease characteristics, morbidity, mortality and survival outcomes between the two groups was made.

RESULTS

From January 2013 to December 2017, 79 patients underwent CRS (TPP-30, SPP-49) with or without intraperitoneal chemotherapy (IPC). The median PCI was 14 for TPP and 8 for SPP. The 90-day grade 3-4 morbidity (23.3% for TPP, 14.2% for SPP, p = 0.58) the 90-day mortality was similar (p = 0.58). The median disease free survival (DFS) was 37 months for SPP and 33 months for TPP (p = 0.47) and median overall survival (OS) not reached for both. The 3-year OS was 95% for TPP and 70.8% for SPP (p = 0.06). The only independent predictor of OS was grade 3-4 morbidity (p = 0.01) and not TPP (p = 0.09). Microscopic residual disease was seen in 23.3% with normal looking peritoneum in TPP group.

CONCLUSIONS

TPP was not associated with increased morbidity compared to SPP. There was a trend towards a longer OS in the TPP group and the finding of residual disease in 'normal looking' peritoneum' warrants prospective evaluation of the benefit of TPP in this setting.

Individualized Chemotherapy Benefit Prediction by EndoPredict in Patients With Early Breast Cancer in an Indian Cohort

PURPOSE

There are new advancements in the modulation of the treatment of patients with early-stage breast cancer, including the use of several molecular profiling tests to identify or select those patients who require additional adjuvant chemotherapy together with hormonal therapy on the basis of a recurrence score. One such tool is EndoPredict (Myriad Genetics; Salt Lake City, UT), which provides support in clinical decision making. The objective of this analysis was to study the landscape of absolute chemotherapy benefit and the likelihood of recurrence within 5 to 15 years in Indian patients with breast cancer who are undergoing EndoPredict testing.

PATIENTS AND METHODS

This study included 308 patients with hormone-positive, human epidermal growth factor receptor 2–negative early breast cancer. Their postsurgical blocks were analyzed using the EndoPredict test. The MEDCALC statistical tool (Panum Education; Seoul, Republic of Korea) was used to estimate the correlation coefficient and to conduct multiple regression analysis.

RESULTS

On the basis of the EndoPredict EPclin Risk Score, 52.12% of patients were classified as being in the low-risk category and could safely forgo adjuvant chemotherapy. For every unit increase in the EPclin Risk Score, the percentage increase in absolute chemotherapy benefit was 6.82%. Similarly, the correlation between the likelihood of recurrence within 5 to 15 years and the EPclin Risk Score suggested that there is a 10.34% increase in recurrence for each unit of EPclin Risk Score.

CONCLUSION

The EPclin Risk Score has good prognostic and predictive power; it also provides the range of chemotherapy benefit for Indian patients.

Palbociclib in hormone positive metastatic breast cancer: A real world multicenter Indian experience

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Background: Palbociclib, a selective CDK4/6 inhibitor, in combination with hormonal therapy has become the standard of care in the treatment of hormonal positive (HR+) metastatic breast cancer (MBC). There is limited efficacy and safety data in Indian patients. Methods: This is a multicenter retrospective study of real world experience of patients with HR+, Her 2 neu negative MBC who received Palbociclib in 5 centers of south India between Oct 2016 and Aug 2019. Endpoints were overall response rate (ORR), progression free survival (PFS) and toxicity. Results: 133 patients received Palbociclib; 83 (62.4%) in the first line setting (hormone naïve MBC) and 50 (37.6%) in the second line (MBC progressed on at least one line of hormonal therapy). Median age was 56 years (range 48-76). All patients started with 125mg/day. In the 83 first line patients, 46 (55.4%) had denovo MBC, 37 (44.6%) had post-adjuvant relapse. 38 (45.8%) had bone only and 45 (54.2%) had visceral metastases. Letrozole was the companion drug in 76%, Fulvestrant in 18%, Exemestane in 6%. 5 (6%) patients achieved complete response (CR), 54 (65%) partial response (PR), 12 (14.5%) stable disease (SD) and 12 (14.5%) had progressive disease (PD). ORR was 71%. At a median followup of 18 months, the median PFS was not reached (maximum ongoing followup 38 months). The median PFS in the denovo metastatic disease versus relapsed disease was not reached versus 18 months (p = 0.021). The median PFS was significantly better in bone only versus visceral metastases (not reached versus 28 months, p = 0.007). In the 50 second line patients, 15 (30%) had bone only and 35 (70%) had visceral metastases. Companion drug was Fulvestrant in 64%, Letrozole in 20%, Exemestane in 16%. 60% received prior chemotherapy. Best response was CR 3 (6%), PR 23 (46%), SD 4 (8%), PD 17 (34%), not assessed 3 (6%). ORR was 52%. The median PFS was 14 months. PFS in bone only versus visceral disease was 14 months versus 13 months (p = 0.382). Neutropenia was present in 75.2%, thrombocytopenia in 19.5%, anaemia in 18%. Neutropenia was grade 1 in 26%, grade 2 in 51%, grade 3 in 23%; with no febrile neutropenia. 30% had dose delays and 8.2% had dose reduction. Conclusions: Palbociclib has resulted in similar efficacy and safety in Indian patients as the PALOMA trials. Neutropenia was the commonest side effect, which was uncomplicated and easily managed with dose delays. Using CDK4/6 inhibitors with hormonal therapy has become the standard of care in HR+ MBC Indian patients.

CRS + HIPEC in stage IIIc epithelial ovarian cancer and comparison of oncological outcome only with CRS and IV chemotherapy and CRS + IP chemotherapy

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Background: Our study aims to describe role of CRS & HIPEC in stage IIIC epithelial ovarian malignancy & compare the oncological outcome (DFS & OS) of extensive CRS+ HIPEC in comparison with CRS & IV chemotherapy & CRS + IP chemotherapy. Methods: Patients diagnosed of stage IIIc EOC underwent extensive CRS + HIPEC. All data prospectively entered in the HIPEC registry was analysed. Outcome of CRS & IV group (n = 50), CRS + IP group (n = 60) operated around same period was compared with the CRS & HIPEC group. Results: Out of 135 patients, upfront, interval and secondary cytoreduction plus HIPEC was done in 29.6%, 44.4% & 25.9% & mean PCI was 14.1, 9.6 & 13.0 respectively. Multi-visceral resection, diaphragmatic resection & bowel resection was required in 12.7%, 50% & 41.8% respectively. Overall G3- G5 morbidity was seen in 25.4% with major being electrolyte imbalance 16.3%, hematological 12.7% & surgical 11.8%. Mean ICU & hospital stay 1.5 & 11 days respectively. Overall 30 day mortality was 4.5%. With a median follow up of 42 months DFS was 30, 33 & 16 months and OS was 70%, 67% & 51% at 4 year for upfront, interval and the recurrent settings respectively. Detailed description presented in Table. Most of the recurrences in CRS & IV group were in peritoneum whereas the other two groups had lesser peritoneal & systemic recurrence. Conclusions: Optimal cytoreduction & some form of IP therapy is needed to improve outcomes. CRS+ HIPEC is feasible in all groups of ovarian cancer with acceptable morbidity & mortality. However the role of single HIPEC in comparison to 6 cycles of IP chemotherapy needs to be evaluated with a well-designed multi-institutional randomised study. [Table: see text]

Real-world experience with Lenvatinib in the management of Hepatocellular Carcinoma: A single-center Indian experience

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Background: Sorafenib has been the standard first line treatment for more than a decade in advanced Hepatocellular carcinoma (HCC) patients. Lenvatinib is a novel oral tyrosine kinase inhibitor which inhibits VEGF receptors 1-3, FGF receptors 1-4, PDGF receptor alpha, RET and KIT, and has activity in multiple cancers. In the recent phase III REFLECT trial, Lenvatinib was non-inferior to Sorafenib in the first line management of advanced HCC. It showed better response rates, improved progression free survival (PFS) with similar overall survival (OS). There is no data of Lenvatinib in Indian patients. Methods: This is a single center, retrospective study, which included patients with metastatic or unresectable HCC who received treatment with Lenvatinib at our center. The endpoints were objective response rate (ORR), PFS and toxicity. Results: 31 patients received Lenvatinib from Dec 2017 to Oct 2019. Patients greater than 60kg received 12mg/day and those less than 60kg received 8mg/day. There were 5 females and 26 males. Median age was 60 years (29-78 years). All patients were BCLC stage C. Child Pugh score was A in 20 patients, B in 9 patients and C in 2 patients. AFP was elevated in 25 (80.6%) patients. 26 patients received Lenvatinib as initial therapy, 3 received it after Sorafenib progression, and 2 received after Sorafenib and Nivolumab progression. 6 patients (19.35%) achieved partial response (PR), 12 (38.7%) had stable disease and 13 (41.9%) had progressive disease by recist criteria. ORR was 19.35% and disease control rate was 58%. 2 patients underwent TACE after achieving PR. The median PFS was 7 months. The common adverse events were hypertension, weight loss, palmar plantar rashes, dysphonia and fatigue. Grade 3 AEs occurred in 8 patients (25.8%). 10 patients (32.2%) required dose reduction due to side effects. Conclusions: Lenvatinib has demonstrated a high response rate and disease control rate in our patients. Achieving a PFS of 7 months is an improvement over our previous Sorafenib experience. Further followup will demonstrate the overall survival. It is well tolerated and most side effects can be managed with patient education. The major advantage has been that in contrast to Sorafenib, only 32.2% patients required dose reduction due to side effects. These results are practice changing and Lenvatinib has become our first line regimen in advanced HCC. Lenvatinib would provide a good backbone to combine immunotherapy as first line treatment in future.

Bowel anastomosis before or after HIPEC: A prospective comparative study in patients undergoing CRS+HIPEC for peritoneal surface malignancy at a tertiary care cancer center in India

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Background: To do bowel anastomosis before or after HIPEC has been debated since the time heat is being used for intraperitoneal chemotherapy after cytoreductive surgery. We report our experience of impact of heat on anastomosis and leak rates. Methods: All patients diagnosed with peritoneal surface malignancy eligible for CRS+ HIPEC as per institution protocol had bowel restoration being performed with stapler & second layer taken. Our institution has two teams, of which one performs anastomosis before and one after HIPEC. All the data was entered prospectively in the HIPEC registry and is being analyzed to see the effect of heat on anastomosis. Results: 220 patients underwent CRS+ HIPEC of which organ of origin was colorectal 39%, stomach 20%, mesothelioma 11%, ovary 20% and others 10%. Upfront cases were 12%, interval 58% & recurrent 30%. Prior surgical score was 0 (62%), 1 (11%), 2 (23%), 3 (4%). 100 patients were in group that had anastomosis before HIPEC and 120 patients in other. Mean PCI 13.4±4.5, blood loss 1250±553.9 ml, duration of surgery 9.5±2.4 hrs, duration of hospital stay 9±3.5 days. Overall 57.05% had bowel resections, of which large bowel was 47.8%, small bowel 17.7%, stomach 6.13%. 19.6% required multivisceral resection & stoma rate was 11.1% for whole group. Both the group had almost same number of total (55.4 %vs 58.6%), small (15.3%vs16.5%) & large bowel resections (44.3%vs 49.5%). We had 4 (1.84%) leak overall, of which 2 were in either groups. Overall G3-4 morbidity was 28.4%, surgical G3-4 was 12.5%, perforation 3.6%, obstruction 1.84%, re exploration was 9.2%. 30-day mortality was 4.9%. Conclusions: We conclude that anastomotic integrity, leak rates & complications related to small or large bowel restoration is same either before or after HIPEC as we observed no difference in our study. However, since this is not a randomized study a well-designed multi-institutional randomized study needs to be planned for stronger evidence of the same.

Toxicity profile of chemotherapy agents used in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies

INTRODUCTION

Morbidity associated with cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is due to the synergistic effect of cytoreduction, effect hyperthermia and the cytotoxic agents used for HIPEC. This study was done to analyse the postoperative morbidity in relation to the chemotherapy agent used in patients undergoing CRS-HIPEC for peritoneal surface malignancy (PSM) in Indian set up.

MATERIALS AND METHODS

Patient with PSM, underwent CRS-HIPEC as per the institutional protocol. Patients were stratified as per the chemotherapy drug used during HIPEC & perioperative outcome were documented.

RESULTS

163 patients underwent CRS-HIPEC for PSM: 67.4% were of ovarian primary. Others were colorectal, appendicular, gastric primary and rare tumors.Cisplatin was the most common drug used: as alone (57.05%) or in combination with Adriamycin (12.88%). Mitomycin-C (MMC) was used in 20% and oxaliplatin in 10%.Grade 3-5 morbidity in the whole cohort was 44.8% and grade 1-2 was 74%.Grade 1-2 electrolyte abnormality was the most common morbidity overall and grade 3-4 hematological toxicity was the most common severe morbidity. Frequency of grade 3-5 morbidity were 38.7%, 48.5%,50% and 61.9% for Cisplatin alone, MMC, oxaliplatin and Adriamycin + cisplatin respectively. None of the patients had grade 3-4 nephrotoxicity as sole complication. All major complications were highest in the group who received Adriamycin. Cisplatin was associated with higher rate of electrolyte imbalance, oxaliplatin with post-operative bleeding. Rates of other complications did not differ significantly.

CONCLUSION

Cisplatin followed by MMC were the well tolerated drugs during HIPEC and tolerance to Adriamycin combination regimen in Indian patients was poor.

Immunotherapy with checkpoint inhibitors in mismatch repair deficient (dMMR) cancers: Looking for a needle in a haystack— But, joy on finding one

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Background: Pembrolizumab is approved for deficient mismatch repair (dMMR) or high microsatellite instability (MSI-H) metastatic solid tumors with objective response rate (ORR) of 39.6% and response lasting for more than 6 months in 78% patients. Nivolumab is also approved in dMMR metastatic colorectal cancers (mCRC) with ORR of 28% and response lasting greater than 6 months in 67% patients. But finding these patients is difficult as only about 5% of metastatic cancers have dMMR. There is limited data from India in this population. We report our experience with testing and treatment in these patients. Methods: This is a single centre, retrospective study of metastatic solid tumors which had progressed on standard treatment. 137 patients were tested between May 2017 and Dec 2018. MMR testing was done by immunohistochemistry (IHC). The aim was to identify patients with dMMR; and to see their ORR, progression free survival (PFS) at 1 year, and adverse events on treatment with Nivolumab. Results: 137 metastatic cancer patients were tested. 75 had colorectal cancer (mCRC), 30 gastric, 10 hepatobiliary, 10 pancreatic, 8 endometrial, 2 small bowel cancer and 2 had breast cancer. 15 (11%) patients had dMMR. 3 (37%) of endometrium, 5 (16.6%) of stomach, 6 (8%) of mCRC and 1(10%) of hepatobiliary tree cancer had dMMR. 5 of the 15 dMMR patients received immunotherapy with Nivolumab - 2 in mCRC, 2 in stomach and 1 in endometrium. ORR was 60% with 3 partial responses, stable disease was seen in 1 (20%) and progression in 1 (20%). PFS at 1 year was 80%. Treatment was well tolerated.1 patient had hypothyroidism and 1 patient had grade 1 skin toxicity. Conclusions: Testing for dMMR is important in metastatic solid tumors as these patients are ideal for treatment with immunotherapy. But finding dMMR is difficult due to its infrequent presentation, and has been seen in 11% of our unselected patients. We recommend testing for dMMR by IHC in our Indian patients, as this is fast and cost effective. Finding dMMR cancers, and then treating with immunotherapy is rewarding irrespective of the site of origin. High ORR of 60% and 1 year PFS of 80% is very heartening to see in this relapsed metastatic patient group. Treating more dMMR patients and longer followup, will further elucidate the benefit of immunotherapy in our patients.

Immunotherapy with nivolumab in metastatic renal cell carcinoma in resource constraint settings: Impact of increasing intervals between standard doses, and stopping treatment early in responding patients

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Background: Nivolumab is now a standard 2nd line treatment for patients of metastatic Renal cell cancer (mRCC) who progress on 1st line Sunitinib or Pazopanib. Most western centers use Nivolumab for either 2 years duration, or indefinitely, or till severe side effects. Due to high drug cost and lack of insurance, it is difficult for most of our Indian patients to afford this duration of treatment. So, we decided to study the impact of increasing intervals between standard doses of Nivolumab, and stopping treatment early in responding patients of mRCC. Methods: This is a single centre, retrospective study of mRCC patients. Nivolumab was given at either 3 mg/kg or 240mg at 2 weekly intervals for the initial 6 cycles. If the patient were found to have either Complete Response (CR), Partial Response (PR) or stable disease, the interval between cycles was extended to 3 weeks (at same dose). After 9 months, the doses were extended to 4 weekly intervals (at same dose). The treatment was stopped at 18 doses in patients with CR or PR. The endpoints were objective response rate (ORR), overall survival (OS) and adverse events (AE). Results: Between May 2016 and Dec 2018, 28 patients received Nivolumab. 24 patients had received oral TKIs initially- 13 Sunitinib, 10 Pazopanib, and 1 Sorafinib. 4 patients received Nivolumab as 1st line therapy (2 as single agent, 2 with oral TKI). Response was assessed by RECIST criteria. 3 patients (11%) achieved CR, 7(25%) achieved PR, 7 (25%) had stable disease and 11(39%)had progressive disease. Treatment was stopped after 18 doses in the 3 patients who had CR. The duration of followup after stopping treatment ranges from 8 months to 18 months, and all 3 patients continue to be in CR. 3 patients with stable disease have received more that 18 cycles (1 at 22 cycles, 2 at 19 cycles). OS at 1 year is 60% and median OS has not been reached. Conclusions: In our experience, Nivolumab is an effective agent in mRCC, even when the dosage intervals are increased, and when the treatment is stopped early in responding patients. An ORR of 36% and a OS at 1 year of 60% is the best we have seen. Long-lasting responses, even after discontinuing therapy, have been seen. This enables us to reduce the cost of treatment without possibly losing efficacy, and this could be an important step forward for treating more patients with Nivolumab in our resource constraint setting.

Abstract P3-03-40: A prospective two arm comparative study of indo-cyanine green (ICG) enhanced fluorescence imaging vs conventional methods (blue dye and radiocolloid/hand held gamma probe) for sentinel lymph node detection in breast cancer - Going beyond the horizon

Background:

The dual technique with radio colloid and blue dye is the gold standard in sentinel lymph node biopsy (SLNB) to stage axilla in breast cancer. However due to cost & infrastructural demands of nuclear medicine department most of the oncology centers are not doing slnb or are doing SLNB with blue dye which is not a standard of care. Indocyanine green (ICG) has recently been used as a method of identifying sentinel lymph nodes. Studies have shown that ICG fluorescence imaging alone or in combination with the blue dye method or the radionuclide method is a safe and easy technique. The objective of the present study was to assess the diagnostic performance of sentinel lymph node (SLN) biopsy using the indocyanine green (ICG) fluorescence method compared with that using the conventional method in detection of sentinel lymph nodes.

Material & Methods:

60 patients diagnosed with early breast cancer underwent the SLNB procedure using technetium-99m radio colloid (R), methylene blue dye (MB), and ICG. Fluorescence imaging was done using an indigenously designed , very economical fluorescence imaging system, Irilic.nm fluorescence imaging along with Indocyanine green. All SLNs that were removed during surgery were labelled as hot, blue or/and fluorescent and sent for pathological examination. The detection rate of SLNs and positive SLNs, and the number of SLNs of ICG, MB+ R, ICG + MB, ICG + R were compared. Injection safety of ICG and MB was evaluated.

Results:

Sentinel Lymph Node was identified in all 60 cases. Total Sentinel lymph nodes removed was 145 (Mean=2, Range 2-5), ICG was able to identify more nodes than the dual dye technique. The identification rate with the dual dye technique was 95%, with blue dye alone 93.6% and with radioisotope alone 96.8% whereas with ICG alone was 100%, with ICG + MB was 96.6% & ICG + R was 96.6 %. 28(46.6%) out of 60 patients had positive nodes which was identified by both dual dye & ICG. None of the patients had any local or systemic reaction with ICG, 3 patients with blue dye had tattooing & staining of skin.

Conclusion:

ICG is as effective as the dual dye for SLNB. ICG is safe & reliable. In addition, as a near-infrared dye, it has the advantages of real-time visualization, lower cost, and wider availability. It can be a boon for developing countries & second tier referral centers of developed country where there is limited access to nuclear medicine department & radiocolloid and even if its accesible the cost involved is too high which comes with added radiation exposure to medical personnel handling them. A combination of blue dye and ICG is useful dual approach when radioisotope is unavailable.

ICG verus Conventional Dye Clinical Profile ICGRadio-colloid+ B;ue DyeDetection Rate100%95%Sensitivity100% (CI 83.16% to 100.00%)100% (CI 83.16% to 100.00%)Positive Predictive Value100%100%Accuracy100%100%

Citation Format: Somashekhar S, Rohit Kumar C, Zaveri S, Rajgopal A, Rakshit S, Ali SH. A prospective two arm comparative study of indo-cyanine green (ICG) enhanced fluorescence imaging vs conventional methods (blue dye and radiocolloid/hand held gamma probe) for sentinel lymph node detection in breast cancer - Going beyond the horizon [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-40.

“Should we be generous in peritonectomy?”: First prospective comparative analysis of total versus involved field parietal peritonectomy in CRS-HIPEC for peritoneal surface malignancies from COLO-rectal cancer—ISPSM collaboration study

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Background: Peritonectomy is the important components in management of peritoneal surface malignancies (PSM). Immunofluoresecne study done after involved field peritonectomy (IFP) has showed diease in areas not suspected on gross examination stressing the need for total parietal peritonectomy (TPP) for complete cytoreduction. The aim of this study was to assess the morbidity & mortality, recurrence pattern & oncological outcomes of extent of parietal peritonectomy with CRS & HIPEC for colorectal carcinoma. Methods: Patients with PSM from CRC underwent TPP or IFP with CRS- HIPEC. Pre & intraoperative data were analyzed with main focus on postoperative morbidity, mortality, recurrence pattern and oncological outcomes. Results: 40 cases of CRC of which four upfront, 17 interval and 19 recurrent cases. 19 & 21 patients underwent TPP & IFP respectively. Base line characteristics were comparable except median PCI (17 versus 12). TPP group had longer duration of surgery (11 vs 9), more blood loss (1300 vs 700 ml) increased diaphragmatic resections ( 46.2% vs 14.2%), multivisceral resection ( 46.2% vs 28.5%). Number of bowel resections, anastomosis and stoma were comparable. Overall TPP group had more G3-G5 morbidity (46.1% vs 35.7%) & surgical morbidity (30.7% vs 21.5%) . TPP group had increased pleural & intra-abdominal collections which needed intervention. With a median follow up of 30 months, DFS was significantly higher in TPP group (12months vs 8months, p < 0.01) and median overall survival was 21 months in IFP group (yet to be achieved in TPP group). TPP group had most of the recurrences in visceral liver & lung (50.0%) followed by peritoneal (37.5%) & nodal (12.5%) whereas in IFP it was peritoneum (42.8%), visceral ( 38.4%) & nodal (15.3%). Conclusions: It is the first prospective comparative study done on total parietal peritonectomy in PSM of colorectal cancer origin. TPP group had significantly higher DFS, with comparable postoperative morbidity. However, longer follow up and a prospective multi-institutional randomized study needs to be designed for more evidence of the same.

Chasing Rainbows? the Possibility of "Cure" in Patients with Colorectal Peritoneal Metastases Undergoing Cytoreductive Surgery and HIPEC-a Retrospective Study by INDEPSO

Cytoreductive surgery (CRS) and HIPEC results in a median disease-free survival (DFS) of 12-15 months, overall survival (OS) of 23-63 months, and cure in around 15% of patients with colorectal peritoneal metastases (CPM). The wide variation in OS may largely be attributed to different criteria for patient selection employed by different investigators. To evaluate outcomes of CRS and HIPEC for CPM in patients enrolled in the Indian HIPEC registry. A retrospective analysis of patients enrolled in the registry since its inception in March 2016 was performed. The impact of various prognostic factors on DFS and OS was evaluated. From Jan 2013 to Dec 2017, 68 patients underwent CRS with HIPEC at six Indian centers. The median PCI was nine [range 3-35]. Twenty-two (32.3%) had mucinous tumors. A CC-0 resection was performed in 53 (77.9%) and CC-1 in 14 (20.5%). The median DFS was 12 months [95% CI 11.037-12.963 months] and the median OS 25 months [95% CI 18.718-31.282]. The DFS was inferior in patients with right upper quadrant involvement (p = 0.02) and 90-day major morbidity (p = 0.002) and OS inferior in those with 90-day major morbidity (p < 0.001) and mucinous tumors with a PCI > 20. The DFS compares well with results obtained by pioneering teams but we have no "cured" patients. Better patient selection and utilization of systemic therapies could in the future improve the OS. There is a compelling need to identify subgroups of CPM that benefit from the addition of HIPEC to CRS.

A prospective study of robotic rectal surgery for carcinoma rectum assessing the functional and oncological outcomes: Hype or hope?

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Background: Robotic surgical systems have dramatically changed minimally invasive surgery as they could potentially address limitations of laparoscopic rectal surgery. This prospective observational study is conducted to evaluate the safety, technique, and outcomes (operative, postoperative,functional and oncological long term) of robotic-assisted rectal surgery for carcinoma rectum in the Indian set up. Methods: This was a prospective observational study conducted between 2010 and 2018, including 135 patients, diagnosed of rectal carcinoma. Patients underwent robotic rectal cancer surgery in form of either low anterior resection (LAR) or abdominoperineal resection (APR). Intraoperative, postoperative data were analysed. Results: Out of 135 patients, 67.5% were male, aged between 34-80 years, 85% had ECOG 0. All patients had adenocarcinoma rectum, with 15% mid rectum and 55% in lower rectum. 85% had stage III disease. 77.5% had received neoadjuvant chemoradiation. 82.5% had LAR and 17.5% APR. Average operative time including docking time and surgery time was 226.32 min (170-300 min), mean blood loss was 146.76 ml (120-200 ml), there were 3 conversion to open surgery. Bowel sounds appeared on average on 3rd day. All margins were negative in all patients, mesorectal grade was complete in 95% and near complete in 5%. Mean number of lymph nodes harvested is 9.5 (2-32). Complete pathological response rate was 39%. 2 patients had anastomotic dehiscence after 1 month. Minor complications were noticed in 10% patients. All had acceptable quality of life and well retained bladder function, with 18% sexual dysfunction. Five year DFS was 85% and OS was 94%. Local recurrence was 2.1%. Conclusions: This is one of the largest single center Indian data available. In conclusion, robotic rectal surgery has several benefits in the treatment and should be part of the armamentarium of the experienced surgeon dealing with rectal cancer. We conclude that the robotic-assisted rectal cancer surgery is safe and an oncologically feasible technique with well retained functional outcomes and has lived up to its hope.

Impact of Radicality Versus Timing of Surgery in Patients with Advanced Ovarian Cancer (Stage III C) Undergoing CRS and HIPEC-a Retrospective Study by INDEPSO

HIPEC in addition to interval CRS has shown a survival benefit of 12 months compared to CRS alone. However, there are many controversial issues pertaining to CRS itself which should be addressed first. To compare NACT and primary CRS approaches when CRS is categorized according to the extent of resection. To evaluate the feasibility of performing HIPEC at these two time points. A retrospective analysis of patients with stage III C ovarian cancer undergoing primary and interval CRS + HIPEC was performed. The surgical approach for interval CRS was classified as (1) resection of sites of residual disease alone or (2) resection of sites involved before NACT. The morphological response was divided into different categories, and surgeons had to state what they consider residual disease and what they do not. From January 2013 to December 2017, 54 patients were included (18-primary; 36-interval). Median PCI 11 vs 6.5 (p = 0.07); CC-0 was obtained in 77.7%. Three surgeons resected previously involved sites; three sites of residual disease only. All surgeons resected areas of scarring. Twenty percent patients had residual disease in "normal-looking" peritoneum. Morbidity (p = 0.09), median OS (p = 0.71), and median DFS (p = 0.54) were similar in the two groups. Early recurrence occurred in 50% with resection of residual disease alone compared to 16.6% when previous disease sites were resected (p = 0.07). Interval CRS should be performed to resect sites involved prior to NACT and not just sites of residual disease. HIPEC can be performed in both primary/interval settings with acceptable morbidity.

Analysis of Clinical Outcomes of Pseudomyxoma Peritonei from Appendicular Origin Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy-A Retrospective Study from INDEPSO

To evaluate the clinical outcomes of patients of pseudomyxoma peritonei of appendiceal origin undergoing cytoreductive surgery and HIPEC. Data collected from members, an independent collaborative group of Indian surgeons specializing in the management of peritoneal surface malignancy (INDEPSO), was analyzed retrospectively. Clinicopathological and perioperative outcomes of patients treated for pseudomyxoma peritonei (PMP) of appendicular origin were evaluated. Ninety-one patients were diagnosed with pseudomyxoma peritonei of appendicular origin between March 2013 and December 2017. The median age was 53 years and 60% were females. The median PCI was 27 [range 3-39] and a CC-0/1 resection was achieved in 83.5% patients. The most common histological grade was low-grade PMP, seen in 71.4% cases. The overall rate of grades 3-4 morbidity was 33% (30/91) and the 90-day mortality rate reported was 6.5%. Pulmonary complications and systemic sepsis emerged as the most significant factors affecting morbidity, mortality, and failure to rescue. At a median follow-up of 24 months, the median OS was not reached and the median PFS was 53 months. On univariate and multivariate analysis, high-grade histology, prior chemotherapy, debulking surgery alone without HIPEC, and high PCI > 10 were predictors of poor progression-free survival. The survival and morbidity results of pseudomyxoma peritonei from appendicular origin following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are encouraging. With further awareness and understanding of the disease, and improvement in surgical expertise and learning curve, there is scope for further reduction in morbidity and better improvement in survival.

Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry

BACKGROUND

The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to  • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry.  • Identify operational problems.

METHODS

A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons' attitudes and existing practices pertaining to the registry and identify operational problems.

RESULTS

During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres.

CONCLUSIONS

These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

Setting up of the Indian HIPEC Registry: A Registry for Indian Patients with Peritoneal Surface Malignancies

There are various registries for patients with peritoneal metastases (PM) that aid pooling of data and generate evidence that dictates current clinical practice. This manuscript describes the setting up of the Indian HIPEC registry that was set up with a similar goal by a group of Indian surgeons. This is a registry for patients with PM treated with CRS and HIPEC in India. It also acts as a database for storing treatment-related information. Patients with PM from colorectal ovarian, gastric, appendiceal tumors, and other rare peritoneal tumors/metastases from rare tumors are enrolled in the registry. A coordinator updates the disease status of patients on a yearly basis. A private organization maintains the database. A non-disclosure agreement is signed between the company and each surgeon contributing to the registry to maintain confidentiality. For enrolling patients, securing institutional permission depends on the requirement of each institute; patient consent is mandatory. Data entry can be prospective or retrospective. To propose and conduct a study, the approval of a scientific committee linked to the registry is required. The Indian HIPEC registry is a practical database for Indian surgeons. There is no regulatory body that mandates collection and publication of scientific data in India. The onus is on each surgeon to capture valuable information pertaining to these common and rare diseases that could contribute to the existing scientific knowledge and guide the treatment of these patients in the future. The next challenge will be to enter data into the registry.

Anaesthetic management of extra-pleural pneumonectomy and hyperthermic intrathoracic chemotherapy procedure

Malignant pleural mesothelioma is a rare tumour with survival of 9-17 months after diagnosis. Radical surgical resection by extra-pleural pneumonectomy combined with hyperthermic intrathoracic chemotherapy has shown to improve patient survival and better microscopic tumour control. Anaesthetic management of this procedure is challenging due to the complex pathophysiological changes associated with prolonged duration of surgery, one- lung ventilation, haemodynamic instability due to major blood loss, temperature variations including heat loss during pneumonectomy and rapid rise in temperature during hyperthermic chemotherapy, cardiac arrhythmias due to exposure to heated chemotherapeutics, cisplatin toxicity and acid-base changes. Intra-operative management involves protective ventilation, regulation of temperature and haemodynamics along with prevention of complications associated with 'heated chemotherapeutics'. Thorough pre-operative assessment and preparation, advanced intra-operative monitoring with prompt corrective interventions, will help in improved patient outcome in the immediate post-operative period. We present one such case done for the 1(st) time in India.

The Initial Indian Experience with Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases

Worldwide, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used for nearly 3 decades to treat peritoneal metastases (PM), improve quality of life, and prolong survival substantially in selected patients. In India, the use of the combined modality of treatment dates back a decade with majority of the efforts taking place within the last 5 years. The first PSOGI workshop (India) held in April 2015, at Bangalore, India offered an opportunity for Indian surgeons performing CRS and HIPEC to share their experience. To study the methodologies of CRS and HIPEC (hospital set up, equipment, training and surgical background) as well as the outcomes in terms of perioperative morbidity and mortality and short and long term survival of patients treated in India, Indian surgeons who had treated at least 10 patients with this combined modality were invited to present their experience. Data collection was retrospective. Analysis of the pooled data was carried out. Eight surgeons treated 384 patients with CRS and HIPEC over a period of 10 years. The commonest primary sites were ovary (as first line therapy n = 124), followed by appendix, including pseudomyxoma peritonei (n = 99), colorectum (n = 77), recurrent ovary (as second line therapy, n = 33), stomach (n = 15), primary peritoneal cancer (n = 10), peritoneal mesothelioma (n = 9) and rare tumors in 17 patients. The weighted mean PCI for all 384 patients was 18.25. 349/384 patients (90.88 %) had a complete cytoreduction (completeness of cytoreduction score of CC-0/1). Grade 3-5 complications developed in 108 patients (27.34 %) and 30 day mortality occurred in 28 (7.29 %) patients. This study showed that CRS and HIPEC can be performed with an acceptable morbidity and mortality in Indian patients. Most of the surgeons are on the learning curve and further improvement in these outcomes is expected over a period of time. Pooling of data related to both common and rare peritoneal cancers would be useful in knowing the disease behavior, response to treatment and outcomes in Indian patients. The 2015 PSOGI meeting provided a unique platform for data presentation with feedback from international experts in the field of peritoneal surface oncology. Future meetings are planned to expand the evaluation of Indian data and progress.

Prospective Randomized Study Comparing Robotic-Assisted Surgery with Traditional Laparotomy for Rectal Cancer-Indian Study

Rectal cancer is one of the common cancers in India. Surgical management is the mainstay of initial treatment for majority of patients. Minimally invasive surgery has gained acceptance for the surgical treatment of rectal cancer because, compared with laparotomy, it is associated with fewer complications, shorter hospitalization, and faster recovery. The aim of this study is to evaluate the safety, feasibility, technique, and outcomes (postoperative, oncological, and functional) of robotic-assisted rectal surgery in comparison with open surgery in the Indian population. A prospective randomized study was undertaken from August 2011 to December 2012. Fifty patients who presented with rectal carcinoma were randomized to either robotic arm (RA) or open arm (OA) group. Both groups were matched for clinical stage and operation type. Technique and feasibility of robotic-assisted surgery in terms of operating time, estimated blood loss, margins status, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, complications, and functional outcomes were analyzed. The mean operative time was significantly longer in the RA than in the OA group (310 vs 246 min, P < 0.001) but was significantly reduced in the latter part of the robotic-assisted patients compared with the initial patients. The mean estimated blood loss was significantly less in the RA compared with the OA group (165.14 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 in the OA group (3.6 vs 2.4 cm, P < 0.001). A total of 100 % of patients in the RA group had complete mesorectal excision while two patients in the OA group had incomplete mesorectal excision. The average number of retrieved lymph nodes was adequate for accurate staging. The number of lymph nodes removed by robotic method is slightly higher than the open method (16.88 vs 15.20) but with no statistical significance. Conversion rate was nil. The mean hospital stay was significantly shorter in the RA group (7.52 vs 13.24 days, P < 0.001). Postoperative and functional outcomes were comparable between the two groups. Robotic-assisted surgery is an emerging technique in our country. Robotic-assisted rectal cancer surgery is safe with low conversion rates and acceptable morbidity and is oncologically feasible.

A regimen of weekly nab-paclitaxel with weekly carboplatin in recurrent ovarian cancer: A retrospective analysis

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Background: The standard of care for patients with recurrent platinum resistant ovarian cancer is treatment with non cross-resistant drugs. Carboplatin retreatment is usually not an option in the platinum resistant population. Weekly paclitaxel has been tried in recurrent patients. But paclitaxel can cause hypersensitivity reactions due to its Cremophor based solvent. nab-paclitaxel being a nano-particle albumin bound paclitaxel is devoid of this toxictity. Also, it is thought that nab-paclitaxel may have a higher intratumoral uptake leading to enhanced anti-tumor action. We looked at a regimen using weekly carboplatin with weekly nab-paclitaxel in platinum resistantrelapsed carcinoma ovary who had failed multiple lines of treatment. Methods: We treated 10 patients with recurrent platinum resistant ovarian cancer with measurable disease with nab-paclitaxel 100mg/m2 on days 1,8,15 with carboplatin at AUC 1.5 on days 1,8,15 intravenously, repeated every 28 days for 4 cycles. All patients had received 3 or more lines of chemotherapy for recurrent disease. We looked for response rate, progression free survival and toxicities. Results: Three patients had complete response, 5 patients had partial response and 2 patients had disease progression. Median PFS was 6 months. There were no instances of paclitaxel induced hypersensitivity reactions. Two patients developed grade 3 neutropenia. One patient developed grade 3 thrombocytopenia. Three patients required blood transfusions. One patient developed grade 3 neuropathy. Conclusions: Weekly combination of nab-paclitaxel with weekly carboplatin is a safe and potentially active treatment in recurrent platinum resistant ovarian cancers who had failed multiple lines of treatment. Considering the efficacy and favorable toxicity profile, this weekly combination needs to be tested in a larger number of patients.

Neoadjuvant chemotherapy (NACT) with DCF regimen in stage III, squamous cell cancer: Esophagus followed by oesophagectomy—Indian experience

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Background: Despite improved surgical techniques and peri-operative care in cancer of the esophagus, the 5 yr OS is 10%. Additional therapy could improve prognosis. At least 10 RCTs comparing NACT to surgery alone have demonstrated a significant increase in median survival of 17 months in the former, compared to 13 months in the latter. We aimed at studying impact of NACT in Indian patients and its impact on surgery and outcome. Methods: The study – Prospective non-randomised study. Between 2007-12, 20 patients were included to analyze the benefit of NACT with DCF (docetaxel 75mg/m2 day 1, cisplatin 75mg/m2 day 1, 5-FU 750mg/m2 per day 1-4) regimen, in stage III Ca. Esophagus, assessed by EUS and PET-CT scan , pre-chemo and post-chemo, in biopsy proven Squamous cell Carcinoma Oesophagus. Prophylactic growth factors were used in all cycles. Results: Post NACT, Partial response of 58.8%, and a complete pathological response of 17.6% were observed with response rage of 76.4%. NACT x 3 cycles used. 4 pt.s had mucositis, but none had grade 3 toxicity, neutropenia in 4 pt.s and febrile neutropenia in only one pt., vomiting and fatige in 5 pt.s . Surgery post NACT was, very easy and there was no significant morbidity, or surgical complication nor any mortality observed due to NACT. On follow-up, two patients died due to systemic recurrence and progression disease progression. Two patients had regional and one patient had , non-regional lymph node disease recurrence. In remaining 16 patients, till to date there is no recurrences and are disease free. All but 2 patients are alive to date. Conclusions: The response rate to NACT (TPF-Regimen) is 76.4%, with maximum benefit in the complete responders. NACT has no adverse impact on the surgical outcome. Surgery is done with acceptable morbidity and very low mortality. Surgical resection post NACT was easy. Impact of this regimen on DFS and OS, have to be ascertained over time.