FIGO 2023 endometrial staging: a leap of faith into the new "prognostic based' rather than "anatomical based" staging-too fast too furious??

BACKGROUND

In 2023 FIGO revised the endometrial cancer staging system after 13 years. There is a lacuna of data regarding the performance and practicality of the revised 2023 FIGO staging schema for endometrial cancer from Low Middle-Income Countries (LMIC).

OBJECTIVE

To estimate the shift of stage and adjuvant management of endometrial cancer based on the FIGO 2023 system compared to the FIGO 2009 system and assess the predictive potential of the FIGO 2023 system.

MATERIAL AND METHODS

A retrospective study was conducted from 1st January 2017 to 31st December 2022. All patients with endometrial cancer were staged according to the FIGO 2023 and FIGO 2009 staging system. Follow-up of patients was done to determine recurrence.

RESULTS

A total of 152 patients were included. Aggressive histology was seen in 66 (45%) patients. Eighteen (11%) had subserosal involvement. Substantial LVSI was noted in 23 (15%) of patients. Twenty-four (47%) patients of FIGO 2009 Stage IA and 26 patients (63%) of FIGO 2009 Stage IB were upstaged. Eleven (50%) patients of FIGO 2009 Stage IIIA were down staged to IA3. Overall 23 patients (15%) had a shift of stage. Fifteen out of 152 patients (15%) would have had a possible risk stratification change which would imply 23 patients (15%) would have needed a more radical treatment. Molecular classification was done in 32 patients; however, only 2 patients could afford POLE testing. Kaplan-Meier curves showed significant PFS differences in FIGO 2009 Stage IB and Stage IIIA when restaged according to the FIGO 2023 system.

CONCLUSION

The FIGO 2023 endometrial staging is a more robust prognosticator; however, the practicality of molecular classification in LMICs is still a distant dream.

Examining the effects of green revolution led agricultural expansion on net ecosystem service values in India using multiple valuation approaches

Ecosystem Services (ESs) are bundles of natural processes and functions that are essential for human well-being, subsistence, and livelihoods. The 'Green Revolution' (GR) has substantial impact on the agricultural landscape and ESs in India. However, the effects of GR on ESs have not been adequately documented and analyzed. This leads to the main hypothesis of this work - 'the incremental trend of ESs in India is mainly prompted by GR led agricultural innovations that took place during 1960 - 1970'. The analysis was carried out through five successive steps. First, the spatiotemporal Ecosystem Service Values (ESVs) in Billion US$ for 1985, 1995, and 2005 were estimated using several value transfer approaches. Second, the sensitivity and elasticity of different ESs to land conversion were carried out using coefficient of sensitivity and coefficient of elasticity. Third, the Geographically Weighted Regression model was performed using five explanatory factors, i.e., total crop area, crop production, crop yield, net irrigated area, and cropping intensity, to explore the cumulative and individual effects of these driving factors on ESVs. Fourth, Multi-Layer Perceptron based Artificial Neural Network was employed to estimate the normalized importance of these explanatory factors. Fifth, simple and multiple linear regression modeling was done to assess the linear associations between the driving factors and the ESs. During the observation periods, cropland, forestland and water bodies contributed to 80%-90% of ESVs, followed by grassland, mangrove, wetland and urban built-up. In all three evaluation years, the highest estimated ESVs among the nine ES categories was provided by water regulation, followed by soil formation and soil-water retention, biodiversity maintenance, waste treatment, climate regulation, and greenhouse gas regulation. Among the five explanatory factors, total crop area, crop production, and net irrigated area showed strong positive associations with ESVs, while cropping intensity exhibited a negative association. Therefore, the study reveals a strong association between GR led agricultural expansion and ESVs in India. This study suggests that there should be an urgent need for formulation of rigorous ecosystem management strategies and policies to preserve ecological integrity and flow of uninterrupted ESs and to sustain human well-being.

Standard-dose versus high-dose radiotherapy with concurrent chemotherapy in esophageal cancer: A prospective randomized study

Objective:

The objective of this study is comparision of local and distant control rates with high-dose versus standard-dose radiotherapy along with concurrent chemotherapy in esophageal cancer – a prospective randomized study.

Materials and Methods:

Histologically proven Stage I–III patients with carcinoma esophagus were randomized into two groups. One group has been treated with standard-dose radiotherapy, i.e., a total dose of 50.4 Gy (1.8 Gy/day, 28#, 5 days/week). The other group (study arm) has received high-dose radiotherapy, i.e. a total dose of 64.8 Gy (1.8 Gy/day, 36#, 5 days/week). Both groups have received 2 cycles of 3 weekly concurrent chemotherapy (cisplatin 75 mg/m^[2] on day 1 and 5-fluorouracil 750 mg/m^[2] continuous intravenous infusion over 24 h on day 1–4). Follow-up response evaluation was done by both endoscopy and computed tomography scan after 6–8 weeks and after 2 months thereafter.

Results:

Out of a total of 28 patients, 68% showed a complete response, 14% showed partial response, and 18% patients developed progressive disease at first and subsequent follow up (median follow-up of 21 months). Among the complete response patients, rates were higher in high-dose group compared to standard-dose radiotherapy group (71% vs. 64%, P = 0.38). Treatment-related toxicities were acceptable in both groups.

Conclusion:

High-dose radiotherapy with concurrent chemotherapy seems to be more effective with acceptable toxicity in our study. However, further follow-up and large sample size may be required to validate the current study conclusion.

Identification of Conservation Priority Zones Using Spatially Explicit Valued Ecosystem Services: A Case from the Indian Sundarbans

Demarcation of conservation priority zones (CPZs) using spatially explicit models is the new challenge in ecosystem services (ESs) research. This study identifies the CPZs of the Indian Sundarbans by integrating 2 different approaches, that is, ESs and ecosystem health (EH). Five successive steps were followed to conduct the analysis: First, the ESs were estimated using biophysical and economic methods and a hybrid method (that combines biophysical and economic methods); second, the vigor-organization-resilience (VOR) model was used for estimating EH; third, the risk characterization value (RCV) of ESs was measured using the function of EH and ESs; fourth, Pearson correlation test was performed to analyze the interaction between ESs and EH components; and fifth, the CPZs were defined by considering 7 relevant components: ecosystem vigor, ecosystem organization, ecosystem resilience, RCV, EH, ESs, and the correlation between EH and ESs. Among the major ecoregions of the Sundarbans, the highest ESs value in economic terms is provided by the mangrove ecosystem (US$19 144.9 million per year). The highest conservation priority score was projected for the Gosaba block, which is dominated by dense mangrove forests. The estimated CPZs were found to be highly consistent with the existing biodiversity zonations. The outcome of this study could be a reference for environmentalists, land administrators, researchers, and decision makers to design relevant policies to protect the high values of the Sundarbans ecosystem. Integr Environ Assess Manag 2020;16:773-787. © 2020 SETAC.

Examining the effects of forest fire on terrestrial carbon emission and ecosystem production in India using remote sensing approaches

Remote sensing techniques are effectively used for measuring the overall loss of terrestrial ecosystem productivity and biodiversity due to forest fires. The current research focuses on assessing the impacts of forest fires on terrestrial ecosystem productivity in India during 2003-2017. Spatiotemporal changes of satellite remote sensing derived burn indices were estimated for both fire and normal years to analyze the association between forest fires and ecosystem productivity. Two Light Use Efficiency (LUE) models were used to quantify the terrestrial Net Primary Productivity (NPP) of the forest ecosystem using the open-source and freely available remotely sensed data. A novel approach (delta NPP/delta burn indices) is developed to quantify the effects of forest fires on terrestrial carbon emission and ecosystem production. During 2003-2017, the forest fire intensity was found to be very high (>2000) across the eastern Himalayan hilly region, which is mostly covered by dense forest and thereby highly susceptible to wildfires. Scattered patches of intense forest fires were also detected in the lower Himalayan and central Indian states. The spatial correlation between the burn indices and NPP were mainly negative (-0.01 to -0.89) for the fire-prone states as compared to the other neighbouring regions. Additionally, the linear approximation between the burn indices and NPP showed a positive relation (0.01 to 0.63), suggesting a moderate to high impact of the forest fires on the ecosystem production and terrestrial carbon emission. The present approach has the potential to quantify the loss of ecosystem productivity due to forest fires.

Responses of ecosystem services to natural and anthropogenic forcings: A spatial regression based assessment in the world's largest mangrove ecosystem

Most of the Earth's Ecosystem Services (ESs) have experienced a decreasing trend in the last few decades, primarily due to increasing human dominance in the natural environment. Identification and categorization of factors that affect the provision of ESs from global to local scales are challenging. This study makes an effort to identify the key driving factors and examine their effects on different ESs in the Sundarbans region, India. We carry out the analysis following five successive steps: (1) quantifying biophysical and economic values of ESs using three valuation approaches; (2) identifying six major driving forces on ESs; (3) categorizing principal data components with dimensionality reduction; (4) constructing multivariate regression models with variance partitioning; (5) implementing six spatial regression models to examine the causal effects of natural and anthropogenic forcings on ESs. Results show that climatic factors, biophysical factors, and environmental stressors significantly affect the ESs. Among the six driving factors, climate factors are highly associated with the ESs variation and explain the maximum model variances (R² = 0.75-0.81). Socioeconomic (R² = 0.44-0.66) and development (R² = 27-0.44) factors have weak to moderate effects on the ESs. Furthermore, the joint effects of the driving factors are much higher than their individual effects. Among the six spatial regression models, Geographical Weighted Regression (GWR) performs the most accurately and explains the maximum model variances. The proposed hybrid valuation method aggregates biophysical and economic estimates of ESs and addresses methodological biases existing in the valuation process. The presented framework can be generalized and applied to other ecosystems at different scales. The outcome of this study could be a reference for decision-makers, planners, land administrators in formulating a suitable action plan and adopting relevant management practices to improve the overall socio-ecological status of the region.

Remote sensing based deforestation analysis in Mahanadi and Brahmaputra river basin in India since 1985

Land use and land cover (LULC) change has been recognized as a key driver of global climate change by influencing land surface processes. Being in constant change, river basins are always subjected to LULC changes, especially decline in forest cover to give way for agricultural expansion, urbanization, industrialization etc. We used on-screen digital interpretation technique to derive LULC maps from Landsat images at three decadal intervals i.e., 1985, 1995 and 2005 of two major river basins of India. Rain-fed, Mahanadi river basin (MRB) attributed to 55% agricultural area wherein glacier-fed, Brahmaputra river basin (BRB) had only 16% area under agricultural land. Though conversion of forest land for agricultural activities was the major LULC changes in both the basins, the rate was higher for BRB than MRB. While water body increased in MRB could be primarily attributed to creation of reservoirs and aquaculture farms; snow and ice melting attributed to creation of more water bodies in BRB. Scrub land acted as an intermediate class for forest conversion to barren land in BRB, while direct conversion of scrub land to waste land and crop land was seen in MRB. While habitation contributed primarily to LULC changes in BRB, the proximity zones around habitat and other socio-economic drivers contributed to LULC change in MRB. Comparing the predicted result with actual LULC of 2005, we obtained >97% modelling accuracy; therefore it is expected that the Dyna-CLUE model has very well predicted the LULC for the year 2025. The predicted LULC of 2025 and corresponding LULC changes in these two basins acting as early warning, and with the past 2-decadal change analysis this study is believed to help the land use planners for improved regional planning to create balanced ecosystem, especially in a changing climate.

Cancer and cure: A critical analysis

Cancer is one of the most dreaded diseases of the 20th century and spreading further with continuance and increasing incidence in the 21st century. The situation is so alarming that every fourth person is having a lifetime risk of cancer. India registers more than 11 lakh new cases of cancer every year, whereas, this figure is above 14 million worldwide. Is cancer curable? The short answer to this question is "Yes." In fact, all cancers are curable if they are caught early enough. Cancer cells continue to grow unless one of four things occur: (1) The cancerous mass is removed surgically; (2) using chemotherapy or another type of cancer-specific medication, such as hormonal therapy; (3) using radiation therapy; or (4) the cancer cells shrink and disappear on their own.

Land-use and land-cover change in Western Ghats of India

The Western Ghats (WG) of India, one of the hottest biodiversity hotspots in the world, has witnessed major land-use and land-cover (LULC) change in recent times. The present research was aimed at studying the patterns of LULC change in WG during 1985-1995-2005, understanding the major drivers that caused such change, and projecting the future (2025) spatial distribution of forest using coupled logistic regression and Markov model. The International Geosphere Biosphere Program (IGBP) classification scheme was mainly followed in LULC characterization and change analysis. The single-step Markov model was used to project the forest demand. The spatial allocation of such forest demand was based on the predicted probabilities derived through logistic regression model. The R statistical package was used to set the allocation rules. The projection model was selected based on Akaike information criterion (AIC) and area under receiver operating characteristic (ROC) curve. The actual and projected areas of forest in 2005 were compared before making projection for 2025. It was observed that forest degradation has reduced from 1985-1995 to 1995-2005. The study obtained important insights about the drivers and their impacts on LULC simulations. To the best of our knowledge, this is the first attempt where projection of future state of forest in entire WG is made based on decadal LULC and socio-economic datasets at the Taluka (sub-district) level.

ACUTE NORMOVOLEMIC HEMODILUTION IN PATIENTS UNDERGOING ELECTIVE MAJOR SURGERY

Efficacy of acute normovolemic hemodilution in patients undergoing elective major surgery was studied with the aim to evaluate optimum technique, safety and utility in the service. Forty adult patients undergoing elective major surgery, who were in ASA GD I with preoperative haemoglobin more than 10.0g% were included in this study after a detailed explanation of the procedure and obtaining consent. 350-700 ml of patients' blood was collected before induction of anaesthesia and was kept in the operation theatre at room temperature. This was followed by rapid infusion of crystalloid calculated at the rate of 3ml for every ml of blood withdrawn. Intraoperative blood loss, serial haemoglobin assessment, change in pulse rate, blood pressure, SpO₂ and urine output were carefully monitored. The blood was reinfused once haemostasis was secured at the end of surgery. All the vital parameters were maintained within normal limits throughout the procedure. This simple, easy and inexpensive technique was found to be very useful in obviating the necessity of other forms of blood transfusion and preventing all transfusion related hazards. It was found that this method has an important role in patients with uncommon blood groups and has an excellent patient acceptability. This technique has an important role in peripheral service hospitals, where formal blood bank facilities do not exist.

HOMOLOGOUS BLOOD TRANSFUSION: DO WE HAVE ANY ALTERNATIVES?

Homologous blood transfusion, despite numerous and serious transfusion associated hazards, is an important treatment modality. Transmission of infectious agents like HIV, hepatitis viruses, malaria, etc is a distinct possibility notwithstanding careful screening of the blood. Predeposit autologous blood transfusion (PABT) and per operative acute normovolemic haemodilution (ANH) are two comparatively safer, simpler and practical alternatives. Unfortunately, their potential remains unexploited. Earnest motivation efforts at PABT and ANH have paid handsome dividends in our hospital. These have now become very popular amongst surgeons as well as the patients. These techniques can be easily adapted at all hospitals to reduce the demand for homologous blood transfusion. ANH can be safely practised even in hospitals without a blood bank.