Outcomes of minimal access cytoreductive surgery (M-CRS) and HIPEC/EPIC vs. open cytoreductive surgery (O-CRS) and HIPEC/EPIC in patients with peritoneal surface malignancies: a meta-analysis

Introduction

Minimal Access Surgery (MAS) has shown better peri-operative outcomes with equivalent oncological outcomes in gastrointestinal and thoracic oncology. Open CRS (O-CRS) procedure accompanies inevitable and significant surgical morbidity in patients. The aim of the review article is to compare outcomes of M-CRS and HIPEC/EPIC with open procedure in peritoneal surface malignancies.

Content

Comprehensive search of databases was done and total 2,807 articles were found (2793-PubMed and 14-Cochrane review). PRISMA flow chart was prepared and 14 articles were selected. Meta-analysis was performed according to PRISMA guidelines using random-effects model (DerSimonian Laird) and fixed effect model. Publication bias was tested with Funnel plot and Egger's regression test. Quality of studies was assessed by Newcastle-Ottawa scale.

Summary and Outlook

Patients in both groups [total (732), M-CRS(319), O-CRS(413)] were similar in demographic characteristics. Peri-operative outcomes were significantly better in M-CRS group in terms of blood loss SMD=-2.379, p<0.001 (95 % CI -2.952 to -1.805), blood transfusion RR=0.598, p=0.011 (95 % CI 0.402 to 0.889), bowel recovery SMD=-0.843, p=0.01 (95 % CI -1.487 to -0.2), hospital stay SMD=-2.348, p<0.001 (95 % CI -3.178 to -1.519) and total morbidity RR=0.538, p<0.001 (95 % CI 0.395 to 0.731). Duration of surgery SMD=-0.0643 (95 % CI -0.993 to 0.865, p=0.892) and CC0 score RR=1.064 (95 % CI 0.992 to 1.140, p=0.083) had no significant difference. Limited studies which evaluated survival showed similar outcomes. This meta-analysis shows that M-CRS and HIPEC/EPIC is feasible and has better peri-operative outcomes compared to open procedure in patients with limited peritoneal carcinoma index (PCI) peritoneal surface malignancies. Survival outcomes were not calculated. Further studies are warranted in this regard.

Surgery for lung cancer: insight from a state cancer centre in India

Purpose

Lung cancer is one of the most common cancers in India. However, less than half receive treatment with a curative intent and very few undergo surgery amongst them. We present our surgical experience with non-small cell lung cancer.

Methods

A retrospective analysis of a cohort of 92 non-small cell lung cancer patients operated with curative intent.

Results

Less than 2% patients of lung cancer were operated on at our centre. Adenocarcinoma was the most common histological subtype. Right upper lobectomy was the most common surgery performed. Two- and 3-year overall survival was 74.3% and 70.6% respectively. Two- and 3- year disease-free survival was 65.4% and 60.8% respectively.

Conclusion

The fraction of patients who are operated for lung cancer is very less. There is a definite missed window of opportunity. We have comparable survival to international data.

'AJ's Orbicularis Oris Stitch: A Novel and Simple Technique of Reconstructing Central Arch Mandibular Defects in Resource-Constrained Set Up'

Lip and oral cavity SCC account for 2nd highest incidence of cancers and 3rd most common cause of mortality from cancer in India. Reconstruction of defects of central arch invading cancers results in poor cosmetic and functional outcomes if free flaps are not used. 30 patients with Oral SCC in the age group 20-75 years requiring central arch segmental mandibulectomy were included. Reconstruction was done with pedicled bipaddled PMMC flap with 'AJ's orbicularis oris stitch' using Fiber wire. Patients were divided into 4 groups according to extent of lip and skin loss post excision of primary tumour. Patients were evaluated with subjective scores for drooling, oral competence and cosmesis. There were 4, 12, 9 and 5 patients in Group A, B, C and D respectively. Mean subjective scores using our technique for drooling, oral competence and cosmesis were 3.75/4,3.75/4 and 3.5/4 for group A, 3.45/4, 3.36/4 and 3.09/4 for group B, 2.8/4, 2.6/4 and 2.3/4 for group C defects and 2.5/4, 3/4 and 2.5/4 for group D defects respectively. Over all scores for all patients were 3.2/4, 3.14/4 and 2.84/4 for drooling, oral competence and cosmesis. This simple, quick and inexpensive technique of reconstruction of central mandibular arch defects can drastically improve cosmetic and functional outcomes in a resource restrained set up. However, long term results and comparison studies are required for standardisation of the technique.

Secretory Carcinoma of Salivary Glands: A Case Series and Review of Literature

Mammary analogue of secretory carcinoma is a recently described entity in WHO 2017 classification of head and neck tumours. It resembles secretory carcinoma of breast. It usually affects the salivary glands and has an indolent behaviour. We reviewed five cases of Mammary analogue of secretory carcinoma in our institute and compared our results with existing literature. All the patients underwent surgical resections and appropriate adjuvant treatment. Immunohistochemistry is an alternative cost effective tool as compared to genetic testing to differentiate secretory carcinoma from its mimickers. Surgery with adequate margins followed by adjuvant therapy is the treatment of choice.

Inguinal Lymph-Node Ratio (LNR) as a predictor of Pelvic Lymph-Node Metastasis in squamous cell carcinoma of penis

OBJECTIVE

To determine the predictors of pelvic lymph-node metastasis in cases of squamous cell carcinoma (SCC) of penis.

METHODS

Data was retrospectively collected from 267 cases of SCC penis that presented at our institute between 2009 and 2019. Univariate and multivariate logistic regression models were used to identify independent significant factors. Receiver Operating Characteristic (ROC) curve was used to determine the cut-off of Lymph-Node Ratio (LNR) and discriminative ability of new model. Survival analysis was done using Kaplan Meier Curve.

RESULTS

Pelvic Lymph-Node Metastasis (PLNM) was pathologically detected in 56 groins (29.2%). A cut-off of 0.25 was calculated for LNR based on ROC. LNR >0.25 (p = 0.003), ENE (p = 0.037), and LVI (p = 0.043) were found significant on multivariate logistic regression. 71.5% showed PLNM in groins with positive LN (PLN) </ = 2 but LNR >0.25 whereas no PLNM was seen in groins with PLN >2 but LNR </ = 0.25. The AUC was 0.918 and 0.821 for LNR and PLN respectively. The probability of finding PLNM was 0% for patients with no risk factors which increased to 83% for 3 risk factors. The 5-year survival was 60% if no PLNM was found as compared to 12.7% if PLNM were found. The survival according to risk score was 81%, 43%, 16% and, 13% for 0, 1, 2 and, 3 risk score respectively.

CONCLUSION

LNR >0.25, LVI and, ENE are independent predictors of PLNM. The discriminative ability of LNR was better than PLN. PLND could be avoided if no risk factors are present.

Development and Internal Validation of a Nomogram Predicting Overall Survival Based on Log ODDS of Positive Lymph-Nodes for Post Radical Cystectomy Patients in Muscle Invasive Carcinoma of Bladder

BACKGROUND

To develop and validate a nomogram based on LODDS (Log ODDS of positive lymph-nodes) for prediction of overall survival (OS) in post radical cystectomy (RC) patients of muscle invasive bladder cancer (MIBC).

MATERIALS AND METHODS

Data was retrospectively collected from 282 cases of MIBC that underwent RC from 2011 to 2017 at our institute. Significant independent predictors were identified using Cox regression model and incorporated into a nomogram to predict 1, 2, and 4-year OS.

RESULTS

Multivariate analysis showed that Neo-Adjuvant Chemo-Therapy (NACT) (P< .001), LODDS (P< .001), T-stage (Pi = .001), CCI (Charlson Comorbidity Index) (P = .034) and grade (P = .003) were independent predictors of OS. The C-index of nomogram (0.740) was higher than that of the American Joint Committee on Cancer (AJCC) staging system (0.614). The bias-corrected calibration plots showed that the predicted risks were in excellent accordance with the actual risks. The results of NRI, IDI, and DCA exhibited superior predictive capability and higher clinical use of the nomogram.

CONCLUSION

A simple, easy to use nomogram to predict OS in cases of MIBC has been constructed. To best of our knowledge, LODDS has been incorporated for the first time. It has superior predictive ability and higher clinical use than AJCC system. It would help the clinicians for better patient counselling, planning follow-up strategies and designing a clinical trial for newer adjuvant therapy (eg immunotherapy) in post radical cystectomy patients of MIBC.

Octogenarians Are the New Sexagenarians: Cruciate-Retaining Total Knee Arthroplasty Is Not Inferior to Posterior-Stabilized Arthroplasty in Octogenarian Patients

Purpose: The primary goal of this study was to compare survivorship and functional results in individuals aged 80 and over who underwent total knee arthroplasty (TKA) with cruciate-retaining (CR) or posterior-stabilized (PS) implants. Methods: We prospectively analyzed the clinical records of two consecutive cohorts for a total of 96 implants in patients aged 80 years or over. The first cohort consisted of 59 consecutive cemented PS cases, while the second cohort comprised 37 consecutive cemented CR cases. The decision to either perform a PS or CR arthroplasty was taken based on preoperative magnetic resonance imaging and intraoperative findings. The clinical evaluation entailed evaluating each patient’s visual analogue scale for pain (VAS), range of motion (flexion and extension), Knee Society Score (KSS), and Oxford Knee Score (OKS). Each patient was clinically evaluated the day before surgery (T0) and at two consecutive follow-ups at least 1 (T1) and 2 (T2) years after surgery. Implant survival was calculated using the Kaplan−Meier method. Results: Both groups showed statistically significant improvements at each follow-up compared with the preoperative values (p < 0.05). The CR group showed a higher flexion degree at T1 than the PS group (116.14 ± 5.57° versus 113.16 ± 7.66°; p = 0.048). No differences were found between the two groups regarding survival rate (chi-squared test p-value = 0.789). Three failures were noted in the CR group, while there were four in the PS group. Conclusions: This prospective clinical study demonstrates that CR and PS TKA had similar clinical outcomes in octogenarians with regard to knee function, postoperative knee pain, and other complications. Prosthesis survivorship for CR and PS TKA were both satisfactory, and in selected octogenarian patients, CR TKA should always be considered because of the reduced surgical time.

Clinical and oncological outcomes of surgery in Anorectal melanoma in Asian population: A 15 year analysis at a tertiary cancer institute

INTRODUCTION

Anorectal malignant melanoma (ARMM) is an aggressive malignancy with dismal prognosis and a 5-year survival rate less than 20% in most of the previous studies. The ideal surgical treatment has still remained controversial. This retrospective study aims at analysing the outcome in patients with ARMM treated with curative surgical resection.

PATIENTS AND METHODS

This is a retrospective study of 38 patients of stage I anorectal malignant melanoma treated with curative surgical resection at our tertiary cancer institute.

RESULTS

WLE (Wide Local Excision) was carried out in 12 patients and APR (abdominoperineal resection) was done in 26 patients. The median overall survival of the entire group in this study was 20 months. Although the median overall survival of WLE patients was higher than those with APR (37 months versus 16 months, respectively), this was not a statistically significant event (P=0.317). The 1-, 2-, 3-, 5-year survival rates were similar with both APR and WLE with no significant difference in the 5-year survival rate (P=0.816); overall 5-year survival rate of just 13%. There were 3 long-term survivors in this study group who survived for more than 10 years.

CONCLUSION

Most patients ultimately succumb to the disease regardless of the management. Both APR and WLE have significant roles in the management depending on the subset of patients selected. Local treatment should be preferred wherever possible. Abdominoperineal resection should be offered in nodal disease or in a recurrent setting.

Log ODDS (LODDS) of positive lymph nodes as a predictor of overall survival in squamous cell carcinoma of the penis

OBJECTIVE

To evaluate the role of logarithmic ODDS (LODDS) in the number of positive lymph nodes and the number of negative lymph nodes as a prognostic metric in the squamous cell carcinoma (SCC) penis.

METHODS

Data were retrospectively collected from 96 cases of SCC penis that underwent bilateral groin dissection between 2010 and 2015 at our institute. Lymph node density (LND) and LODDS were calculated for all the patients and classified according to American Joint Committee on Cancer (AJCC) pN staging. Thresholds for LND (24% and 46%) and LODDS (-0.75 and 0) were established. Multivariate analysis of various cofactors was done with overall survival (OS) as a dependent factor. Three classification systems were compared using receiver operative characteristic (ROC) curve analysis.

RESULTS

Univariate analysis showed that AJCC pN, LND, and LODDS were all significantly correlated with OS. However, only LODDS (HR, 11.185; p = .023) remained an independent prognostic factor through multivariate analysis. LODDS (log-likelihood = 3832 vs. 3798; p < .001) had better prognostic performance than pN and better discriminatory ability than LND (AIC = 3902 vs. 3928). LODDS had better power of discrimination than LND and pN. LODDS could predict survival in lymph node yield (LNY) < 15 (p < .001).

CONCLUSION

LODDS is an independent predictor of OS in the SCC penis and has superior prognostic significance than the AJCC pN and LND classification systems.

Primary chest wall sarcoma; a single institution experience of 3 years

INTRODUCTION

Primary chest wall sarcoma is a rare entity. It can be classified based on its origin, as bone sarcomas or soft tissue sarcomas. Various prognostic factors have been studied in different case series like age, sex, tumor histology, grade, resection margin status, adjuvant treatment, and others. The present study aimed to analyze common histological types, their management by resection and reconstruction and prognosis, in cases presenting at a regional cancer center in western India.

MATERIAL AND METHOD

This was an observational study from a prospectively maintained database. 57 patients with chest wall sarcoma treated with curative intent between January 2016 till January 2019 with a minimum follow-up of 3 months were included in the study. The goals of surgical treatment were to obtain a wide resection margin of 3-4 cm, preserve the function of the chest wall and provide stability and rigidity to protect intrathoracic organs.

RESULTS

The median follow-up of the present patient's cohort was for 20.2 months. Overall two-year survival was 74.7%. Two-year OS and DFS of bone sarcoma were 62.3% and 35% and soft tissue sarcomas were 91% and 71.3%. Ewing's sarcoma had the worst two-year overall survival of 50.6% and chondrosarcoma and fibromatosis had 100% two-year overall survival.

CONCLUSION

Chest wall sarcoma forms a heterogeneous group of tumors. In the present study, Ewing's sarcoma was the most common histology with the worst survival, since they presented in advanced stages. Management should be multidisciplinary and surgical resection should be aggressive to achieve an R0 resection. Reconstruction of chest wall should aim to provide structural and functional stability with minimal morbidity. Frozen section assessment should be utilized whenever in doubt.

A proposed Clino-radio-pathological Risk Scoring System (CRiSS) for prediction and management of inguinal lymph-nodes metastasis in squamous cell carcinoma of the penis

OBJECTIVE

To develop a risk scoring system for prediction of inguinal lymph-node involvement and to suggest a management strategy according to the risk groups based on clinical, radiological and pathological parameters in squamous cell carcinoma (SCC) of penis.

MATERIALS AND METHODS

A retrospective analysis of all patients of SCC penis from 2014 to 2020 at our institute was done. The patients were divided into derivation cohort (2014 to 2019) and validation cohort (2019 to 2020). A total of 10 predictors were analysed in univariate analysis and those found significant were further subjected to multivariate analysis to derive regression coefficient for each. CRiSS scores were assigned based on the coefficients and three groups were created which were correlated with nodal metastasis. The predictive accuracy of the model was assessed by ROC analysis of the derivation cohort and validation cohort.

RESULTS

A total of 102 patients were identified in derivation cohort and 23 patients in validation cohort. Size of the primary >3cm, ulceroinfiltrative growth, involving shaft, ultrasound size of lymph-nodes >1cm, loss of fatty hila, moderate and poor differentiation, and lypmphovascular/perineural invasion were independent predictors of inguinal lymphnode metastasis in multivariate analysis. CRiSS could achieve AUROC of .910 and .887 in derivation and validation cohort respectively. The rate of metastatic lymphadenopathy was 0%, 41.4%, and 89.5% in low, intermediate, and high-risk groups respectively.

CONCLUSIONS

CRiSS can effectively predict inguinal lymph-node metastasis in SCC penis. We suggest a management strategy based on risk groups that will avoid morbidity of groin dissection in many patients.

Coronavirus disease (COVID-19): A systematic review and meta-analysis to evaluate the impact of various comorbidities on serious events

BACKGROUND AND AIMS

Currently there is limited knowledge on medical comorbidities and COVID-19; we conducted a systematic review and meta-analysis to evaluate the impact of various morbidities on serious events in COVID 19.

METHODS

PubMed, Cochrane Central Register of Clinical Trials were searched on April 28, 2020, to extract published articles that reported the outcomes of COVID-19 patients. The search terms were "coronavirus" and "clinical characteristics". ICU admission, mechanical ventilation, ARDS, Pneumonia, death was considered serious events. The comorbidities assessed in the study were Hypertension (HTN), Diabetes mellitus (DM), Cardiovascular diseases (CVD), Chronic obstructive pulmonary disease (COPD) and Chronic Kidney disease (CKD). Subsequently, comparisons between comorbidity patient group and the non-comorbidity patient groups, in terms of serious events were made using the pooled estimates of odd's ratio (OR) RESULTS: We identified 688 published results and 16 studies with 3994 patients were included in the systematic review. Serious events were seen in 526(13.16%) patients. Presence of hypertension with OR 2.95, diabetes mellitus with OR 3.07, Cardio vascular disease with OR 4.58, COPD with OR 6.66 and Chronic kidney disease with OR 5.32 had significant association in patients with COVID 19 on having serious events. Presence of diabetes mellitus (OR 2.78)) had a significant impact on death in COVID 19 patients with a p-value 0.004.

CONCLUSIONS

Presence of medical comorbidities in COVID-19 leads to higher risk of developing serious events i.e. ICU admission, mechanical intubation and mortality. The presence of Diabetes mellitus has a significant impact on mortality rate in COVID-19 patients.

Hoffa's Fracture with Associated Injuries Around the Knee Joint: An Approach to a Rare Injury

Fractures of the distal femur typically occur in the axial and sagittal planes. A Hoffa fracture is a coronal plane fracture of the femoral condyle, which accounts for 8.7% to 13% of distal femoral fractures. It is usually associated with other injuries around the knee joint and hence is often missed. We conducted a comprehensive systematic review of papers published in the English language using PubMed, Web of Science, Scopus, and the Cochrane Database, which reported Hoffa's fracture associated with other injuries around the knee joint. We selected 11 eligible papers for final analysis and review. These papers had 12 patients with Hoffa’s fracture, with associated injuries around the knee joint. The associated injuries with Hoffa’s fracture were in the ipsilateral distal femur, proximal tibia fractures, patellar dislocation, patella fracture, and patellar tendon incarceration. The management principles for Hoffa's fracture with associated injuries around the knee joint are: having a high clinical index of suspicion for these injuries, obtaining all trauma series radiographs and computed tomography of the knee, achieving complete articular incongruity, and restoring the functions of the knee joint.

Functional Outcome and Incidence of Osteoarthritis in Operated Tibial Plateau Fractures

BACKGROUND

In the challenging tibial condyle fractures despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury. The aim of the study was to know incidence of osteoarthritis in our operated cases of tibial plateau fracture and to evaluate functional outcome.

METHODS

Our operated 60 patients of tibial plateau fractures between 2006 to 2013 were evaluated retrospectively. Pre-operative radiographs were classified using Schatzker classification. Patients were followed up clinically and radiologically and were assessed for functional outcome and development of osteoarthritis.

RESULTS

The average duration of follow up was 76.32 months ranging from 42 to 130 months. The average age was 41.28 (20-73) years. According to Schatzker classification type VI accounted for 32.5% and type V for 20 %. Average VAS Score was 1.35 ranging from 0 to 4. According to American knee society scoring system, 47patients had excellent and 8 patients had good knee scores, while 52 patients had excellent, 4 patients had good and 1 patient had poor functional scores. According to Ahlback classification 25 patients had grade I, while 9 patients had grade II, 7 patients had grade III and 3 patients had grade IV osteoarthritis of knee.

CONCLUSION

Incidence of osteoarthritis goes higher with Schatzker's grading. Despite presence of radiological arthritis patients can have good clinical function if the articular reduction and limb alignment are maintained. Treatment goals should include a congruent articular reduction, adequate knee stability, anatomical limb alignment and avoidance of complications.

LEVEL OF EVIDENCE

IV.

In-vitro effect of human cathelicidin antimicrobial peptide LL-37 on dengue virus type 2

Human Cathelicidin antimicrobial peptide LL-37 is known to have antiviral activity against many viruses. In the present study, we investigated the in-vitro effect of LL-37 on dengue virus type 2 (DENV-2) infection and replication in Vero E6 cells. To study the effect of pretreatment of virus or cells with LL-37, the virus was pretreated with different concentrations of LL-37 (2.5μM-15μM) or scrambled (Scr) LL-37(5μM-15μM) and used for infection or the cells were first treated with LL-37 and infected. To study the effect of LL-37 post infection (PI), the cells were infected first followed by addition of LL-37 to the culture medium 24h after infection. In all conditions, after the incubation, the culture supernatant was assessed for viral RNA copy number by real time RT-PCR, infectious virus particles by focus forming unit assay (FFU) and non structural protein 1 (NS1) antigen levels by ELISA. Percentage of infection was assessed using immunoflourescence assay (IFA). The results revealed that pretreatment of virus with 10-15μM LL-37 significantly reduced its infectivity as compared to virus control (P<0.0001). Moreover, pretreatment of virus with 10-15μM LL-37 significantly reduced the levels of viral genomic RNA and NS1 antigen (P<0.0001). Treatment of virus with 10-15μM LL-37 resulted in two to three log reduction of mean log₁₀ FFU/ml as compared to virus control (P<0.0001). Treatment of the virus with scrambled LL-37 had no effect on percentage of infection and viral load as compared to virus control cultures (P>0.05). Pretreatment of cells before infection or addition of LL-37 to the culture 24h PI had no effect on viral load. Molecular docking studies revealed possible binding of LL-37 to both the units of DENV envelope (E) protein dimer. Together, the in-vitro experiments and in-silico analyses suggest that LL-37 inhibits DENV-2 at the stage of entry into the cells by binding to the E protein. The results might have implications for prophylaxis against DENV infections and need further in-vivo studies.

Hoffa's fracture with ipsilateral fibular fracture in a 16-year-old girl: An approach to a rare injury

Hoffa's fracture is an uncommon fracture of the femoral condyle with coronal orientation of the fracture line. The mechanism of injury in pediatric Hoffa's fracture is road traffic accident, sports injury, and trivial injury. Clinical examination and proper imaging is important for diagnosis of pediatric Hoffa's fracture because of high chances of missing these injuries which can lead to nonunion and malunion at the fracture site. Open reduction and anatomical reduction of intraarticular fragment is the gold standard treatment of these fractures. We present a rare case of Hoffa's fracture in a 16-year-old girl with asso ciated ipsilateral fibular fracture.