Standardizing Surgical Management of Retroperitoneal Sarcomas: Dawn of a New Surgical Subspeciality in India

BACKGROUND

Retroperitoneal sarcomas are a complex and heterogenous group of tumors. An approach to these tumors should be guided by a clear understanding of the disease biology and anatomical principles, which mandates a dedicated multidisciplinary team approach at all steps of management. We present our experience of evolution as a high-volume sarcoma center with a dedicated multidisciplinary tumor board (the RP clinic) with consequent standardization of surgeries and management protocols.

METHODS

A retrospective analysis of a prospectively maintained database for patients undergoing surgery from January 2011 to June 2023 was performed. Data were divided into the pre-clinic era (2011-2017) and post-clinic era (2018-2023). Survival curves were obtained using the Kaplan-Meier method, and the Chi-square test was used to test significance for categorical variables. Time trends were analyzed using the one-way analysis of variance (ANOVA) test. A p value ≤ 0.05 was considered significant.

RESULTS

Overall, 254 patients were operated during this period; 36.6% of patients underwent surgeries in the pre-RP clinic era (6 years) and 63.3% in the post-RP clinic era (4.5 years). There was a statistically significant increase in the number of cases being operated per year, from an average of 16.3 in the pre-clinic era to 42.4 in the post-RP clinic era (p = 0.001). The post-RP clinic era also showed a significant increase in compartment and multivisceral resections (49% vs. 18.2%; p = 0.0001).

CONCLUSIONS

Establishment of a dedicated multidisciplinary tumor board (RP clinic) resulted in standardization of management protocols, resulting in optimal oncological and surgical outcomes.

Contralateral Nodal Relapse in Well-lateralised Oral Cavity Cancers Treated Uniformly with Ipsilateral Surgery and Adjuvant Radiotherapy With or Without Concurrent Chemotherapy: a Retrospective Study

AIMS

To evaluate the incidence and pattern of contralateral nodal relapse (CLNR), contralateral nodal relapse-free survival (CLNRFS) and risk factors predicting CLNR in well-lateralised oral cavity cancers (OCC) treated with unilateral surgery and adjuvant ipsilateral radiotherapy with or without concurrent chemotherapy.

MATERIALS AND METHODS

Consecutive patients of well-lateralised OCC treated between 2012 and 2017 were included. The primary endpoint was incidence of CLNR and CLNRFS. Univariable and multivariable analyses were carried out to identify potential factors predicting CLNR.

RESULTS

Of the 208 eligible patients, 21 (10%) developed isolated CLNR at a median follow-up of 45 months. The incidence of CLNR was 21.3% in node-positive patients. CLNR was most common at level IB (61.9%) followed by level II. The 5-year CLNRFS and overall survival were 82.5% and 57.7%, respectively. Any positive ipsilateral lymph node (P = 0.001), two or more positive lymph nodes (P < 0.001), involvement of ipsilateral level IB (P = 0.002) or level II lymph node (P < 0.001), presence of extranodal extension (P < 0.001), lymphatic invasion (P = 0.015) and perineural invasion (P = 0.021) were significant factors for CLNR on univariable analysis. The presence of two or more positive lymph nodes (P < 0.001) was an independent prognostic factor for CLNR on multivariable analysis. CLNR increased significantly with each increasing lymph node number beyond two compared with node-negative patients.

CONCLUSION

The overall incidence of isolated CLNR is low in well-lateralised OCC. Patients with two or more positive lymph nodes have a higher risk of CLNR and may be considered for elective treatment of contralateral neck.

Central versus distal pancreatectomy for low-grade and benign pancreatic neck-body tumours

PURPOSE

Central pancreatectomy (CP) offers parenchymal preservation compared to conventional distal pancreato-splenectomy for pancreatic neck and body tumours. However, it is associated with more morbidity. This study is aimed at evaluating the peri-operative and long-term functional outcomes, comparing central and distal pancreatectomies (DPs).

METHODS

Retrospective analysis of patients undergoing pancreatic resections for low-grade malignant or benign tumours in pancreatic neck and body was performed (from January 2007 to December 2022). Preoperative imaging was reviewed for all cases, and only patients with uninvolved pancreatic tail, whereby a CP was feasible, were included. Peri-operative outcomes and long-term functional outcomes were compared between CP and DP.

RESULTS

One hundred twenty-two (5.2%) patients, amongst the total of 2304 pancreatic resections, underwent central or distal pancreatectomy for low-grade malignant or benign tumours. CP was feasible in 55 cases, of which 23 (42%) actually underwent CP and the remaining 32 (58%) underwent DP. CP group had a significantly longer operative time [370 min (IQR 300-480) versus 300 min (IQR 240-360); p = 0.002]; however, the major morbidity (43.5% versus 37.5%; p = 0.655) and median hospital stay (10 versus 11 days; p = 0.312) were comparable. The long-term endocrine functional outcome was favourable for the CP group [endocrine insufficiency rate was 13.6% in central versus 42.8% in distal (p = 0.046)].

CONCLUSION

Central pancreatectomy offers better long-term endocrine function without any increased morbidity in low malignant potential or benign pancreatic tumours of neck and body region.

Neuroendocrine differentiation in a metachronous metastatic deposit in a case of mature growing ovarian teratoma: A rare occurrence

ABSTRACT

Growing teratoma syndrome is a rare condition seen in non seminomatous germ cell tumor after completion of chemotherapy. Ectodermal, mesodermal and endodermal differentiation is commonly seen in mature teratoma. neuroendocrine differentiation in a metastatic deposit of mature teratoma is rarely reported. We are presenting a case of neuroendocrine differentiation in a long standing metastatic deposit of a mature teratoma.

Oncologic Liver Resections in a Geriatric Population: Peri-operative, Long-Term and Quality-of-Life Outcomes-Experience from a High-Volume Centre in India

BACKGROUND

Elderly patients can often be overlooked as candidates for a major hepatic resection, by virtue of their age. To enable better patient selection for hepatic resections in this age group, we analysed the outcomes of liver resections in elderly patients to identify any potential prognostic factors.

METHODS

We conducted a retrospective review of a prospectively maintained database of hepatic resections from 1 January 2010 to 31 October 2021 and analysed the post-operative outcomes in patients aged 65 years or older. Short-term outcomes were analysed in terms of length of hospital stay, 90-day major morbidity, and 90-day mortality. Long-term outcome was defined by the disease-free survival, overall survival and quality of life.

RESULTS

Over a period of 11 years, 170 elderly patients underwent oncologic liver resections, of which 68 (40%) underwent a major hepatectomy. The overall morbidity and mortality rates were 32.8% and 5.3%, respectively. Extent of hepatic resection, increasing age, concomitant resection of other organs and a biliary-enteric anastomosis were independent predictors for poor immediate post-operative outcomes. Median disease-free survival and overall survival were 30 months and 78 months, respectively. The global health status was excellent in majority of patients with a mean score of 88.62.

CONCLUSION

Major oncologic liver resections can be performed in well-selected geriatric population with acceptable peri-operative, long-term and quality-of-life outcomes.

Intra-operative enteroscopic polypectomy-An innovative hybrid approach using straight sticks

Background

Peutz-Jeghers Syndrome (PJS) is an uncommon intestinal polyposis disorder. Bowel obstructions are a recurring problem in PJS and as many as 50% of these patients require surgery. The current standard of care for these patients is to perform a flexible enteroscopic polypectomy. The traditional push-pull enteroscopy however, might be unavailable or unsuitable in an emergency setting. Alternatively, repeated laparotomies with multiple small bowel resections can lead to short bowel syndrome.

Methods

In our series, we describe an innovative technique where a short midline laparotomy permitted sufficient access to reduce the intussusception(s) and perform a bowel walk. Rigid laparoscopic instruments were introduced within the small bowel lumen via enterotomies, to perform polypectomies along the entire small bowel length. This precludes the need for small bowel resections which can thwart the development of short bowel syndrome.

Results

Two patients with PJS presenting with acute small bowel obstruction underwent surgery using the described approach. Another two patients with PJS having multiple intussusceptions on CT underwent an elective prophylactic polypectomy using the same approach. We were able to run the bowel in its entirety and a maximum of 41 polyps were retrieved from the port site enterotomy. The operating times were modest and no unique complications pertaining to this technique were encountered.

Conclusion

Small bowel polypectomy using rigid instrumentation employing a limited midline laparotomy is an attractive option for both emergency and elective settings in patients with PJS.

•

Bowel obstructions are a recurring problem in PJS.

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Polypectomy using rigid instrumentation serves as an attractive option for patients with PJS, undergoing a laparotomy for acute bowel obstruction.

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This technique can be empolyed in both, elective as well as emergency settings.

Axial giant cell tumor - current standard of practice

Giant cell tumors of bone are relatively rare in the axial skeleton, accounting for approximately 6.7% of all cases. Due to their anatomical complexity, difficult access and proximity to vital neurovascular structures, management of these tumors poses a huge challenge on the treating surgeon. Several data series reported on axial GCTB involve short series of limited cases with varied methods used in their local control due to which, proper guidelines are unavailable for the management of such difficult cases. Though the present data support the use of denosumab for effective management of these lesions but there is varied consensus on dosage and duration of treatment. This review article summarizes the basic features and treatment modalities related to axial GCTB stressing on multidisciplinary approach to achieve optimum outcomes.

Is release of the posterior lamella enough? A cadaveric exploration of posterior component separation techniques

BACKGROUND

As posterior component separation techniques continue to gain popularity there is uncertainty regarding the degree of fascial advancement afforded by the various techniques. Our study seeks to compare the degree anterior rectus sheath translation seen in full transversus abdominus release compared to simple release of the posterior lamella of the rectus sheath.

METHODS

Ten hemi-abdomens in five fresh cadavers were dissected. One hemi-abdomen underwent external oblique release. The contralateral hemi-abdomen underwent retrorectus dissection and initial release of the internal lamella of the internal oblique, followed by full transversus abdominus release. A 4 kg weight was suspended from the fascia and excursion was measured after 1) external oblique separation, 2) posterior lamella of the internal oblique separation, and 3) transversus abdominis separation.

RESULTS

Average unilateral hemifascial translation after release of the external oblique provided an average unilateral hemi-fascial translation of 3.38 cm (+/- 0.69). Release of the posterior lamella of the internal oblique provided 3.98 cm (+/- 0.94). After transversus release the average translation increased to 4.31 cm (+/- 0.89).

CONCLUSIONS

In this cadaveric study, the majority (92%) of fascial advancement afforded by posterior component separation was achieved by an intermediate step in the transversus abdominus release operation: division of the posterior lamella of the internal oblique.

Evaluation of Web Portal for Improving Cancer Awareness in General Population in India

Background: With details on various cancers and recent advances in cancer prevention, a Web portal was developed to create awareness and value added education among Web-users in general population in villages, small towns and large cities of India. Aim: The Web portal aims at bringing awareness at the 3 levels of health related education program delivery success/efficacy triangle. The 1st level is cognitive learning of just being aware of cancer & basic knowledge. The 2nd level is a positive effect to be able to adopt life style changes that will lead to habit changes in diet, substance abuse and other life style habits and adherence to prescribed treatment. The 3rd level is actual behavioral change. Methods: A mixed methods study design incorporating etic-emic & qualitative research methodology and quantitative cross-sectional methods. We also used focused group discussions and in-depth interviews as part of qualitative study designs. Results: On the basis of data from the 100 participants, the Web portal was found to have improved attitudes toward accessing information related to cancer in participants. There was also an increase in the knowledge of the people, both general population and level 1 healthcare worker as compared with their previous knowledge about cancer. Also found was improvement in knowledge about the prevalent cancers, their screening procedures and general measures of prevention and treatment. Conclusion: On the basis of participants evaluated, we found that the Web portal may have a positive effect on cancer awareness of general population. Participants found the Web portal as a relevant tool to access information in the feedback. The comprehensive data which will be available after feedback from all participants, will help in understanding the nature of user´s response to Web based resources and its implications in improving lifestyle choices and promoting early screening & early detection of cancer.

SPINS-IND: Pellet injector for fuelling of magnetically confined fusion systems

Using a Gifford-McMahon cycle cryocooler based refrigeration system, a single barrel hydrogen pellet injection (SPINS-IND) system is indigenously developed at Institute for Plasma Research, India. The injector is based on a pipe gun concept, where a pellet formed in situ in the gun barrel is accelerated to high speed using high pressure light propellant gas. The pellet size is decided by considering the Greenwald density limit and its speed is decided by considering a neutral gas shielding model based scaling law. The pellet shape is cylindrical of dimension (1.6 mm ℓ × 1.8 mm φ). For pellet ejection and acceleration, a fast opening valve of short opening duration is installed at the breech of the barrel. A three-stage differential pumping system is used to restrict the flow of the propellant gas into the plasma vacuum vessel. Diagnostic systems such as light gate and fast imaging camera (240 000 frames/s) are employed to measure the pellet speed and size, respectively. A trigger circuit and a programmable logic controller based integrated control system developed on LabVIEW enables to control the pellet injector remotely. Using helium as a propellant gas, the pellet speed is varied in the range 650 m/s-800 m/s. The reliability of pellet formation and ejection is found to be more than 95%. This paper describes the details of SPINS-IND and its test results.

Twice-weekly palliative radiotherapy for locally very advanced head and neck cancers

PURPOSE

The purpose of the following study is to evaluate the efficacy of a twice-weekly hypofractionated palliative radiotherapy schedule in locally very advanced head and neck cancers.

MATERIALS AND METHODS

Patients with locally very advanced, head and neck cancers were prospectively evaluated after twice-weekly palliative radiotherapy regimen of 32 Gy in 8 fractions. Median age was 55.5 years and the predominant primary site was oral cavity (46%). Majority (70.6%) had Stage IV B disease. Disease related distressing symptoms such as pain, bleeding, skin fungation, respiratory symptoms due to tumor burden, were prospectively assessed before the start of treatment, at conclusion and at 6-12 weeks of completion of treatment.

RESULTS

A total of 126 patients were enrolled in the study. Ninety three (73.8%) patients who completed the planned treatment of 32 Gy in 8 fractions were included in the symptom analysis. Overall response rates were 42% at primary disease and 55% at nodal disease. At conclusion of radiotherapy 76.3% of the patients reported improvement in pain scores (P = 0.001) and 42.8% patients reported improvement in anxiety and depression levels (P = 0.001). At first follow-up after 6-12 weeks significant improvement in pain scores (P = 0.001) and anxiety/depression levels (P = 0.001) persisted. The median survival of the patients was 5.5 months. Acute grade III mucositis was seen in one patient (1.2%) while none had grade III skin reactions.

CONCLUSION

The proposed radiotherapy regimen is effective for sustained symptom palliation with low acute toxicity in locally very advanced head and neck cancers. It delivers a moderately high dose while being logistically simpler for the patient.

Abstract P3-12-08: Are different therapeutic approaches required after skin and nipple sparing mastectomies for locoregional control? A single institution's experience

Introduction

Nipple sparing (NSM) and skin sparing (SSM) mastectomies are gaining popularity. These procedures leave breast tissue at the skin/breast interface with the intent to better cosmesis. However, the impact of NSM versus SSM on risk of local recurrence in the remaining breast tissue is not well characterized, nor is the effect of post mastectomy radiotherapy (PMRT) in these patients.

Methods

A single institution retrospective study was conducted on women treated with NSM or SSM from 2005 to 2011 with follow up through 2015. Chest wall and chest wall or axillary recurrence were assessed. Factors associated with recurrence were examined. Kaplan Meier estimates and Cox proportional hazards models were used to analyze chest wall recurrence (CWR) and chest wall or axillary recurrence (CWAR), with CWAR as the primary outcome variable.

Results

This analysis identified 181 women who underwent a SSM (n=103, 58 (56%) with PMRT) or NSM (n=78, 35 (45%) with PMRT). Women undergoing SSM were older (56.0 ± 13.6 years, mean ± SD) than NSM (44.6 ± 11.3, p &lt;0.0001) while follow-up times were similar (4.91 ± 0.43 and 5.43 ± 0.27 respectively, p = 0.15). Women undergoing PMRT were younger (49.2 ± 13.6 vs 53.1 ± 13.9 years, p = 0.008) but more likely to present with lymphovascular space invasion (LVSI)(42% vs 16%, p = 0.0003 by Chi-square), and were more likely to receive chemotherapy (83% vs 47%, p &lt;0.0001). The majority of women (62%) in the group not receiving PMRT had stage I disease, and 79% were node negative. For those undergoing PMRT, 83% were stage II or III, and 69% were node positive (p &lt;0.0001 for both differences). Despite the higher apparent risk of the PMRT group, the total number of chest wall or axillary recurrences was similar (8 in PMRT, 6 in no PMRT). Event-free survival for CWAR at 5 years was 92% for PMRT and 96% for no PMRT (p=0.42) and at 7.5 years, 85% and 84% respectively (p=0.42). In univariate Cox regression among all patients, age was the strongest predictor of CWAR (HR = 1.103 per year of age, 95% CI 1.053-1.154, p&lt;0.0001). CWAR occurred in 2.6 % of NSM patients as compared with 11.8% of SSM patients (p=0.025 by Fisher's exact test). SSM versus NSM was associated with increased hazzard for CWAR with HR = 4.6 (95% CI 1.03-21, p=0.046) on univariate analysis. However, this apparent risk became non-significant (HR = 2.24, 95% CI 0.48 – 10.5) with adjustment for age. Other variables associated with CWAR on univariate analysis included receipt of chemotherapy (HR = 0.28, 0.09-0.86, p=0.027) and estrogen receptor positive status (HR = 0.34, 0.12-0.98, p=0.046) but these also became non-significant with adjustment for age. In multivariate Cox regression analysis, use of PMRT was associated with a non-significant higher risk of CWAR (HR = 1.45, 0.33-6.4, p=0.63 ) adjusting for age, LVSI, mastectomy type, stage, and ER status.

Conclusions

The risk of a chest wall or axillary recurrence for early stage breast cancer after a SSM or NSM appears to be low at five years. Radiation can likely be omitted in this group. Furthermore, despite presenting with more advanced disease, women who underwent PMRT experienced excellent locoregional control. Further research is needed on this topic.

Citation Format: Hopkins ZH, Frandsen J, Poruk KE, Agarwal J, Poppe MM. Are different therapeutic approaches required after skin and nipple sparing mastectomies for locoregional control? A single institution's experience. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-08.

Analysis of carbapenem-resistant Acinetobacter from a tertiary care setting in North India

Multidrug-resistant (MDR) Acinetobacter baumannii is a worldwide concern as cause of serious nosocomial infections. We analysed 140 non-duplicate Acinetobacter sp. isolates from hospitalised patients in a tertiary care centre; 87% were MDR and 20% (28/140) meropenem resistant. Metallo-β-lactamase was produced by 16 of these, detected by ethylene-diamine-tetra-acetic acid disc synergy test. AmpC β-lactamase and efflux pump were present in 17 and 4 of the meropenem-resistant Acinetobacter, respectively. 9/16 MBL-positive isolates carried genes for carbapenem resistance as shown by polymerase chain reaction.

Cure for immune-tolerant hepatitis B in children: is it an achievable target with sequential combo therapy with lamivudine and interferon?

We prospectively studied the HBsAg seroconversion with sequential combination therapy of lamivudine (LAM) and interferon (IFN) in hitherto untreatable 'immune-tolerant' chronic hepatitis B in children. In this case-control study, 28 children with immune-tolerant hepatitis B [HBsAg positive for >6 months with near normal aminotransferase level, minimal/no inflammation in liver histology and high viral load (HBV DNA>10(7) copies/mL)] were treated with LAM alone at 3 mg/kg/day for 8 weeks followed by LAM plus IFN alpha (5 MU/m(2) three times a week) for another 44 weeks. They were compared with 34 untreated children. HBV markers (HBsAg, HBeAg, anti-HBe, quantitative HBV DNA) were carried out at baseline, at the end of therapy and 6 monthly thereafter. The mean age was 5.9 ± 3.2 years and 24 were boys. End therapy response: HBe seroconversion was achieved in 11, and of these, five had complete response (HBsAg clearance), 11 did not respond and six had virologic response (DNA undetectable but no HBe seroconversion). Six months after therapy, 10 of the 11 (91%) originally seroconverted children remained seroconverted while one seroreverted. Six of the 28 (21.4%) children lost HBsAg and they remained HBsAg negative and anti-HBs positive on follow-up. After a mean follow-up of 21.1 ± 11.9 months, the status remained same in the responders but one of the nonresponders HBe seroconverted (39.3%). There were no serious side effects of therapy. It is possible to achieve a cure in more than one-fifth of immune-tolerant children with hepatitis B with the sequential combination of LAM and IFN.

Quadriplegia in a child following adenotonsillectomy

Neurological deterioration in a child following routine surgery, although rare, has potentially life threatening consequences. We report the case of a child who, following adentonsillectomy, developed quadriplegia and acute respiratory distress due to previously undetected atlanto-axial instability. Patients with atlanto-axial instability often have mild or non-specific symptoms, despite severe cervical cord compression. Subtle manifestations may be ignored or attributed to other disease processes, which render patients with undiagnosed atlanto-axial instability at risk of serious neurological injury during general anaesthesia, particularly at the time of laryngoscopy and tracheal intubation.

Abstract P4-14-02: National Trends and Indications for Nipple-Sparing Mastectomy: An Analysis Using the Surveillance, Epidemiology, and End Results (SEER) Database

Introduction: Nipple-sparing mastectomy (NSM) is an evolving procedure occasionally used for breast cancer treatment. However, indications for NSM are institution-specific and lack consensus in the literature. This study uses the Surveillance, Epidemiology, and End Results (SEER) database to investigate the oncologic and demographic characteristics of breast cancer patients treated with NSM in the United States from 2005–2009.

Methods: Female breast cancer patients treated from 2005–2009 with nipple-sparing/subcutaneous mastectomy (SEER code 30), defined as removal of breast tissue with preservation of nipple-areolar complex and overlying skin, were included. Variables analyzed included patient age, race, tumor stage, tumor size, lymph node status, and radiotherapy delivery.

Results: A total of 449 female breast cancer patients who underwent NSM were isolated from the SEER database. The number of patients in the SEER database who underwent NSM increased steadily each year, from 66 in 2005 to 133 in 2009. Mean age was 52 years (s.d. 12 years). Breakdown by race showed that 369 (82%) patients were White women, 42 (9%) were Black women, 36 (8%) were of Asian descent. A majority of patients (402) were documented to have ductal or lobular carcinoma. Documented tumor diameter was less than 3 cm in 63% (284) of patients. Invasive cancer was documented in 283 (63%) patients; in situ cancer was documented in 166 (37%) patients. Lymph node involvement was negative in 374 (83%) patients. Radiation therapy was delivered to 91 (20%) patients; however, 64 patients receiving radiation therapy were node-negative. Radiation was delivered to 6% (10) of patients with in situ cancer and 27% (77) of patients with invasive cancer (p &lt; 0.0001).

Conclusions: The number of NSM procedures reported in SEER for breast cancer has increased from 2005–2009. However, there is a lack of consensus in the literature as to which patients may be candidates for NSM. By utilizing a national database, we are able to aggregate and report on the national experience with therapeutic NSM, to date. Patients undergoing NSM for breast cancer were characterized predominantly by tumors less than 3 cm in diameter and with negative lymph node involvement. Patients with both invasive and in situ tumors were considered suitable candidates for NSM. A majority of patients had either ductal or lobular carcinomas. A minority of patients received radiation therapy, although there was a tendency towards providing patients with invasive tumors with radiation therapy. This national data should help guide patient selection for NSM, although future studies are needed to report on the long-term oncologic safety of this procedure.

Pathogenomics of uropathogenic Escherichia coli

Subset of faecal E. coli that can enter, colonize urinary tract and cause infection are known as uropathogenic E. coli (UPEC). UPEC strains act as opportunistic intracellular pathogens taking advantage of host susceptibility using a diverse array of virulence factors. Presence of specific virulence associated genes on genomic/pathogenicity islands and involvement of horizontal gene transfer appears to account for evolution and diversity of UPEC. Recent success in large-scale genome sequencing and comparative genomics has helped in unravelling UPEC pathogenomics. Here we review recent findings regarding virulence characteristics of UPEC and mechanisms involved in pathogenesis of urinary tract infection.

Symptom-based diagnosis of urinary tract infection in women: are we over-prescribing antibiotics?

BACKGROUND

Current clinical guidelines for the management of symptoms suggesting urinary tract infection recommend empiric antibiotic therapy.

OBJECTIVE

To determine the diagnostic accuracy of urinary tract symptoms for early identification of urinary tract infection (UTI) in sexually active women when culture results are not available.

METHOD

This was a cross-sectional observational study conducted in a tertiary care hospital between July 2009 and May 2011. Subjects comprised 312 women ≥ 18 year of age who reported to the physician with symptoms suggestive of UTI. A predesigned questionnaire was filled and urine was analysed by microscopic examination and culture. Diagnostic values were calculated against gold standard urine culture results (> 10(2) CFU/ml) and 95% CIs and likelihood ratios are reported.

RESULTS

A total of 312 women were enrolled, as culture was contaminated in 36 only 276 women were included in final analysis. Prevalence of UTI was 46.01% amongst symptomatic women. Urgency (p = 0.001), burning sensation during micturition (p = 0.035), dysuria (p = 0.004), frequency of sexual intercourse > 5 per month (p = 0.010) and pyuria (p = 0.000) were significantly associated with culture positivity. Absence of pyuria emerged as best predictor for ruling out UTI even if the woman had symptoms (sensitivity 93.70%, NPV 91.84%, AUC 77.07%, LR- 0.1). The combination of urgency, burning during micturition and pyuria was the best predictor of UTI in our study (sensitivity 85.83%, PPV 71.71%, AUC 78.48%, LR+ 2.97)

CONCLUSION

Symptoms alone have low accuracy when assessed against the reference standard for diagnosing UTI. Empiric treatment of UTI based on symptoms may expose large number of patients to unnecessary antibiotics. Wet mount microscopy for presence of pyuria as a 'near patient test' before starting antibiotics seems a rational approach for management of UTI in symptomatic women.

P2-16-03: Outcomes of Nipple-Sparing Mastectomy (NSM) and Immediate Reconstruction

Background

Nipple-sparing mastectomy (NSM) is the surgical removal of breast tissue that preserves the entire skin envelope including the nipple areola skin (NAS). We report our experience performing NSMs and immediate breast reconstruction for both high-risk breast cancer treatment and prophylaxis over a six-year period at The University of Utah and Huntsman Cancer Hospital.

Methods: A retrospective chart review was performed on patients undergoing NSM from April 2005 - April 2011. Data collection included: patient demographics, oncologic details, surgical information (including reconstruction timing and type), and complications (infection, hematoma, seroma, skin necrosis, NAS complication, skin flap loss, premature expander exchange/removal, and capsular contracture).

Results: 130 patients underwent 205 NSMs. Of these, 106 (81.5%) patients received mastectomy treatment for cancer while 24 (18.5%) patients were prophylactically treated. 102 NSMs (49.8%) were on breasts with biopsy-proven cancer, while 103 (50.2%) NSMs were on breasts for prophylaxis. All patients were female with a mean age of 44.7 years (range, 16–82 years). 119 (92.2%) patients were Caucasian, 3 (2.3%) were Asian, and 1 (0.8%) was Hispanic. The mean weight was 65.2 kg (range, 42.8 - 98.8 kg) and BMI (n=106) was 23.7 kg/m2 (SE±0.4). 14 (10.9%) and 12 (9.3%) of the patients were known to have a BRCA1 and BRCA2 mutation, respectively. Two (1.6%) patients had a p53 mutation. 172 (83.5%) of the nipples were spared via an 8 cm incision lateral to the midpoint of the areola, while 5 (2.4%) of the incisions were made along the IMF. The remaining 28 (13.7%) incisions were made by other techniques. 201 (98.0%) breasts were immediately reconstructed with tissue expanders (193 went on to implant reconstruction and 8 underwent autologous tissue reconstruction). 4 (2.0%) breasts received delayed reconstruction. Positive margins were found in 15 (7.3%) of 205 breasts. 60 (58.8%) of 102 cancerous breasts that underwent NSM were Stage 0-I, 35 (34.3%) were Stage II and the remaining 8 (7.8%) were Stage III - IV. Complications by case (Table 1) and by breast (Table 2) are shown below.

P4-15-02: Clinical and Epidemiological Correlates of Elevated Distress Thermometer Scores in Breast Cancer Patients

Objectives: Distress is prevalent in breast cancer patients and can be detrimental to quality of life, performance status, treatment adherence, and satisfaction with medical care. The National Comprehensive Cancer Network (NCCN) developed the Distress Thermometer (DT) as a quick and efficient self-assessment tool for screening distress in cancer patients. While surveys estimate that between 20–40% of patients with cancer have significant levels of distress, fewer than 10% are identified and treated. Given time and monetary constraints, it is important to refine screening criteria to identify patients with elevated risk for distress. In this study, we identify clinical and epidemiological factors that are associated with an increased likelihood of elevated DT scores (≥4 and ≥7) in breast cancer patients.

Methods: We assessed 229 consecutive female patients with the DT at their initial consultation for breast cancer at the Huntsman Cancer Hospital between September 2007 and December 2008. The DT screening tool measures a global level of distress using a visual analogue scale from 0–10 in the shape of a thermometer, with zero identified as “No Distress” and ten labeled as “Extreme Distress.” The DT screening tool also includes a checklist of common emotional, family, physical, practical, and spiritual concerns with instructions for the paitent to indicate which of those concerns contributed to the distress they experienced within the past week. We chose a score ≥4 as our cutoff for a positive screen for “distress” and a score ≥7 as our cutoff for a positive screen for “extreme distress/depression” based on previous studies. Variables included in the analyses were: age, employment status, race/ethnicity, personal history of depression, family history of breast cancer, marital status, estrogen and progesterone receptor status, stage of cancer, time since diagnosis, and recurrence. Descriptive statistics and logistic regression models were used to determine associations between DT and patient data. Results: Emotional and physical concerns were associated with scores ≥4 and scores ≥7. Spiritual concerns were significantly associated with patients reporting scores ≥7. Patients who were non-Caucasian, unemployed, had a prior history of depression, who presented for recurrent disease, or who had been recently diagnosed had a higher likelihood of scores ≥4 and scores ≥7.

Conclusions: The likelihood of scoring ≥4 and ≥7 on the DT screening tool is highest during the first 30 days after receiving a breast cancer diagnosis. Four groups of patients should be targeted for aggressive screening: patients with a prior diagnosis of depression, patients presenting with recurrent disease, unemployed patients, and non-Caucasian patients. Interventions should address physical, emotional and spiritual concerns.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-02.

Patterns of failures after definitive conformal radiation therapy for head and neck cancers

e17037

Background: The primary objective of the study is to analyze patterns of failure in patients with head and neck cancer treated with definitive conformal radiotherapy with a focus on the location of failures in relation to the target volume coverage. Methods: Sixty patients with squamous cell carcinoma (stage: T1–3, N0–2b) were treated definitively on a prospective protocol with conformal techniques to conventional dose-fractionation equivalent of 70 Gy to the gross disease using standardized contouring guidelines. The recurrent or persistent tumor volume (Vf) was defined using positron imaging tomography (PET) and surgical-pathologic findings, and analyzed using dose-volume histograms. The failure was considered marginal when 20%-95% of Vf was within 95% isodose line. Results: At median follow-up of 12 months (range, 4–30) the 3-year actuarial local control, loco-regional control, disease-free survival, and overall survival Kaplan-Meier estimates were 86.4%, 80.5%, 62.6%, and 46.4% respectively. Of 12 (19.3%) patients with disease related events, 10 have loco-regional failures with a median time of 4 months (range, 0–22). Of 10 patients, 8 had in-field, one had marginal and one had failures of both patterns. Of seven (11.3%) local failure events, two were isolated and one had marginal failure. Of seven regional failure events, two were marginal including one with failure at peri-parotid contra-lateral neck. Another one had bilateral multiple nodal levels with supraclavicular recurrence. The remaining events were in-field were “true failures” with no apparent technical cause, none had out-field failures. Two patients were detected to have distant metastases and two developed second malignancies, one out-field and other marginal with upper esophagus carcinoma at gradient zone of previous radiation. Conclusions: Conformal radiotherapy does not compromise loco-regional control as compared to historical controls treated with conventional techniques. PET scans are useful in delineation of failure volumes. The majority of recurrences were ‘in-field‘ motivate studies of dose escalation to the highest risk regions and marginal failures in the high-dose gradient region highlight the potential hazard of high precision techniques and warrants careful consideration.

No significant financial relationships to disclose.

Cerebral venous congestion during cardio-pulmonary bypass: role of bispectral index monitoring

A 58-year-old male patient was posted for double valve replacement under hypothermic cardiopulmonary bypass (CPB). During aortic cross-clamp (AXC), the central venous pressure (CVP) was found to have increased to 22 mmHg. After 4 minutes of sustained increase in CVP, burst suppression (SR) started increasing. After 5 min of increase in SR, bispectral index (BIS) declined rapidly to 17. Propofol infusion was stopped and re-evaluation of signs of facial congestion showed changes to that effect. The perfusionist noted steadily decreasing venous return. As soon as the superior vena cava (SVC) cannula was withdrawn by 3 cm, CVP immediately declined to 6 mmHg. The venous return in the CPB reservoir normalized and BIS returned to 42 after a transient rise to a maximum of 58 and SR decreased to 0 within 2 min of repositioning of the venous cannula. The patient was successfully extubated after 7 hours without any sequelae.

Comparison of closed loop vs. manual administration of propofol using the Bispectral index in cardiac surgery

BACKGROUND

In recent years, electroencephalographic indices of anaesthetic depth have facilitated automated anaesthesia delivery systems. Such closed-loop control of anaesthesia has been described in various surgical settings in ASA I-II patients (1-4), but not in open heart surgery characterized by haemodynamic instability and higher risk of intra-operative awareness. Therefore, a newly developed closed-loop anaesthesia delivery system (CLADS) to regulate propofol infusion by the Bispectral index (BIS) was compared with manual control during open heart surgery.

METHODS

Forty-four adult ASA II-III patients undergoing elective cardiac surgery under cardiopulmonary bypass were enrolled. The study participants were randomized to two groups: the CLADS group received propofol delivered by the CLADS, while in the manual group, propofol delivery was adjusted manually. The depth of anaesthesia was titrated to a target BIS of 50 in both the groups.

RESULTS

During induction, the CLADS group required lower doses of propofol (P<0.001), resulting in lesser overshoots of BIS (P<0.001) and mean arterial blood pressure (P=0.004). Subsequently, BIS was maintained within +/- 10 of the target for a significantly longer time in the CLADS group (P=0.01). The parameters of performance assessment, median absolute performance error (P=0.01), wobble (P=0.04) and divergence (P<0.001), were all significantly better in the CLADS group. Haemodynamic stability was better in the CLADS group and the requirement of phenylephrine in the pre-cardiopulmonary bypass period as well as the cumulative dose of phenylephrine used were significantly higher in the manual group.

CONCLUSION

The automated delivery of propofol using CLADS was safe, efficient and performed better than manual administration in open heart surgery.

Radiation recall dermatitis with gatifloxacin: a review of literature

Radiation recall dermatitis (RRD) is a hypersensitivity skin reaction at the previously irradiated site after the administration of certain pharmacologic agent, which recovers on stopping the medication. RRD is a well-recognized phenomenon with the use of chemotherapeutic agents; however, only a few cases have been reported with noncytotoxic antibiotics, despite their common use in patients with cancer. We report here a case of RRD with the use of gatifloxacin and describe the time dose factors of radiation exposure, characteristics of skin reactions, management and response and our reasons to label this case as RRD. We also discuss published work regarding proposed mechanisms, histological features, radiation dose threshold and response to rechallange with the RRD-triggering drug. If RRD is to be characterized unequivocally, all the potential areas of confusion must be clarified like radiosensitization, nonhealing of acute reactions and skin-related adverse effects of the RRD-triggering drug. With the same objective, we further discussed radiosensitization and photosensitizing potential of fluoroquinolones. Gatifloxacin, although devoid of photosensitivity reactions, may cause idiosyncratic hypersensitivity reaction to cause RRD and should be considered as a potential cause of RRD. Given the potential severity of the reaction and increasing use of gatifloxacin, it is important to be aware of this phenomenon.

MLL-AF9 and FLT3 cooperation in acute myelogenous leukemia: development of a model for rapid therapeutic assessment

Human leukemias harboring chromosomal translocations involving the mixed lineage leukemia (MLL, HRX, ALL-1) gene possess high-level expression, and frequent activating mutations of the receptor tyrosine kinase FLT3. We used a murine bone marrow transplant model to assess cooperation between MLL translocation and FLT3 activation. We demonstrate that MLL-AF9 expression induces acute myelogenous leukemia (AML) in approximately 70 days, whereas the combination of MLL-AF9 and FLT3-ITD does so in less than 30 days. Secondary transplantation of splenic cells from diseased mice established that leukemia stem cells are present at a very high frequency of approximately 1:100 in both diseases. Importantly, prospectively isolated granulocyte macrophage progenitors (GMPs) coinfected with MLL-AF9 and FLT3-ITD give rise to a similar AML, with shorter latency than from GMP transduced with MLL-AF9 alone. Cooperation between MLL-AF9 and FLT3-ITD was further verified by real-time assessment of leukemogenesis using noninvasive bioluminescence imaging. We used this model to demonstrate that MLL-AF9/FLT3-ITD-induced leukemias are sensitive to FLT3 inhibition in a 2-3 week in vivo assay. These data show that activated FLT3 cooperates with MLL-AF9 to accelerate onset of an AML from whole bone marrow as well as a committed hematopoietic progenitor, and provide a new genetically defined model system that should prove useful for rapid assessment of potential therapeutics in vivo.

Chlamydia sp. in hospitalised children with community acquired pneumonia

Our aim was to document the prevalence of chlamydial infection in children less than five years of age with Community Acquired Pneumonia (CAP). Seventy three children, 1 month to 5 years of age, hospitalized with CAP were enrolled over a period of one year. Microimmunofluorescence (MIF) was done to detect IgM antibodies against Chlamydia sp. in sera of all patients; PCR was performed to detect C. pneumoniae DNA in nasopharyngeal aspirates. The prevalence of Chlamydia species infection in CAP in children < 5 years of age was 5.5% (4/73). Two cases were positive for C. trachomatis antibodies; one case was positive for C. pneumoniae antibodies and one case was positive for C. pneumoniae DNA. Chlamydia sp. have an important role in CAP in children < 5 years and for early diagnosis of infection, use of more than one method i.e. PCR and serology both is advisable.

Should early cancers of the oral tongue be kept under surveillance after wide excision alone? A prospective study

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Background: The treatment of the clinically N0 neck in early stage oral tongue cancer remains controversial. Several clinico-pathologic criteria that can reliably identify an increased risk of occult metastases in the neck have been proposed. Our aim was to assess the impact of elective neck dissection (END) on outcome and correlate it with clinico-pathologic criteria for patient selection for surveillance. Methods: Patients with early stage cancer of the oral tongue (T1–2, N0) after undergoing wide excision with or without END were prospectively kept under observation. Patients having adverse histological features necessitating adjuvant radiotherapy were excluded. All patients gave informed consent and were closely followed. Relapsers were offered appropriate salvage therapy. The primary end-point for our prospective phase II study was the impact of END on relapse-free survival (RFS) with an estimated sample size of 50 patients. Overall survival (OS) was a secondary endpoint. Results: Fifty three eligible patients were consecutively accrued on the trial after surgery. Forty eight patients underwent per oral wide excision, with only 5 requiring a neck approach. Twenty two patients underwent upfront END. Twenty four patients relapsed (23 of which had some loco-regional component). The risk of neck recurrence in patients whose necks were not dissected electively was significantly higher than in patients treated with END (55% vs 9% respectively, p = 0.0016). The 3-year RFS (69.1% vs 40.9%, p = 0.008) and OS (87.2% vs 42.6%, p = 0.0228) was significantly better for patients treated with END. Conclusions: Regional recurrences are the most important cause of failure after wide excision alone. END which achieves excellent disease control in the neck and significantly improves RFS and OS should be considered routine for early stage oral tongue cancer.

No significant financial relationships to disclose.

Cryptococcal infection in patients with clinically diagnosed meningitis in a tertiary care center

A retrospective analysis of 326 clinically diagnosed cases with meningitis over a period of five-and-a-half years was carried out to determine the prevalence of cryptococcal infection, its associated risk factors and therapeutic outcome. Fifty-four (16.6%) patients with cryptococcal meningitis were identified by smear examination, culture and/or cryptococcal antigen latex agglutination test. Records of 45 cryptococcal meningitis patients were available; 18 (40%) of them were apparently healthy immunocompetent individuals, 13 (28.9%) had human immunodeficiency virus (HIV) infection, 9 (20%) were renal transplant recipients, 4 (8.9%) were diabetic and 1 (2.2%) had systemic lupus erythematosus. Ten (22.2%) patients died and 11 (24.4%) patients (all HIV-positive) left against medical advice. The present study indicates that cryptococcal infection is associated with high mortality. Presenting symptoms being indistinguishable from other causes of central nervous system infection, all patients with a clinical diagnosis of meningitis, irrespective of their immune status should be investigated for cryptococcal infection.