Anupama Rajanbabu

Virtual Reality Surgical Simulators- A Prerequisite for Robotic Surgery

The field of computer assisted minimally invasive surgery is rapidly expanding worldwide, including in India. With more hospitals in India contemplating the acquisition of a robotic platform, training of robotic surgeons is becoming essential. Virtual reality simulators can be used for surgeons to become acquainted with the robotic console prior to live surgery. Our aim was to evaluate the amount of simulator training required before a surgeon first operates on the da Vinci® Surgical System. Simulations were conducted on the Intuitive Surgical’s da Vinci® Robot Skill Simulator using the software obtained from Mimic Technologies. Participants included attending staff surgeons experienced in robotic surgery and novices. A set of seven activities were chosen for each participant. Based on the mean exercise score from the first attempt, staff surgeons outperformed the novices in all exercises. However, the difference in score between the staff and the novices decreased after the participants repeated the exercises and by the sixth attempt most of the novices obtained similar scores to the staff, suggesting that this might be at present the minimum set of repetitions indicated (or required) prior to performing life robotic surgery.

Brain Metastases in Women With Epithelial Ovarian Cancer: Multimodal Treatment Including Surgery or Gamma-Knife Radiation Is Associated With Prolonged Survival

OBJECTIVE To explore the impact of treatment modality on survival in patients with brain metastases from epithelial ovarian cancer. METHODS We conducted a retrospective review of cases of ovarian cancer with brain metastases treated at institutions in three countries (Canada, China, and India) and conducted a search for studies regarding brain metastases in ovarian cancer reporting survival related to treatment modality. Survival was analyzed according to treatment regimens involving (1) some form of surgical excision or gamma-knife radiation with or without other modalities, (2) other modalities without surgery or gamma-knife radiation, or (3) palliation only. RESULTS Twelve patients (mean age 56 years) with detailed treatment/outcome data were included; five were from China, four from Canada, and three from India. Median time from diagnosis of ovarian cancer to brain metastasis was 19 months (range 10 to 37 months), and overall median survival time from diagnosis of ovarian cancer was 38 months (13 to 82 months). Median survival time from diagnosis of brain metastasis was 17 months (1 to 45 months). Among patients who had multimodal treatment including gamma-knife radiotherapy or surgical excision, the median survival time after the identification of brain metastasis was 25.6 months, compared with 6.0 months in patients whose treatment did not include this type of focused localized modality (P = 0.006). Analysis of 20 studies also indicated that use of gamma-knife radiotherapy and excisional surgery in multi-modal treatment resulted in improved median survival interval (25 months vs. 6.0 months, P < 0.001). CONCLUSION In the subset of patients with brain metastases from ovarian cancer, prolonged survival may result from use of multidisciplinary therapy, particularly if metastases are amenable to localized treatments such as gamma-knife radiotherapy and surgical excision.

The significance of the site of origin in primary peritoneal carcinosarcoma: case report and literature review.

Primary peritoneal carcinomas are rare, highly aggressive malignant neoplasms containing both sarcomatous and carcinomatous elements. Surgical debulking is the mainstay of treatment for primary peritoneal carcinomas. Systemic chemotherapy is advised in all cases because of the early spreading of these tumours. We report on a case of primary peritoneal carcinosarcoma occurring in a 22-year-old woman.

Evolution of surgery in advanced epithelial ovarian cancer in a dedicated gynaecologic oncology unit-seven year audit from a tertiary care centre in a developing country.

Aims To audit our performance as a dedicated gynaecologic oncology unit and to analyse how it has evolved over the years. To retrospectively evaluate the outcome of advanced ovarian cancer treated with neoadjuvant chemotherapy (NACT) followed by interval surgery versus upfront surgery. Methods and results One hundred and ninety-eight patients with advanced epithelial ovarian cancer (EOC) who were treated from 2004 to 2010 were analysed. Eighty-two patients (41.4%) underwent primary surgery and 116 (58.6%) received NACT. Overall, an optimal debulking rate of 81% was achieved with 70% for primary surgery and 88% following NACT. The optimal cytoreduction rate has improved from 55% in 2004 to 97% in 2010. In primary surgery, the optimal debulking rate increased from 42.8% in 2004 to 93% in 2010, whereas in NACT group the optimal cytoreduction rate increased from 60% to 100% by 2010. On the basis of the surgical complexity scoring system it was found that surgeries with intermediate complexity score had progressively increased over the years. There was a mean follow-up of 21 months ranging from 6 to 70 months. The progression-free survival and overall survival (OS) in patients undergoing primary surgery were 23 and 40 months, respectively, while it was 22 and 40 months in patients who received NACT. However, patients who had suboptimal debulking, irrespective of primary treatment, had significantly worse OS (26 versus 47 months) compared with those who had optimal debulking. Conclusions As a dedicated gynaecologic oncology unit there has been an increase in the optimal cytoreduction rates. The number of complex surgeries, as denoted by the category of intermediate complexity score, has increased. Patients with advanced EOC treated with NACT followed by interval debulking have comparable survival to the patients undergoing primary surgery. Optimal cytoreduction irrespective of primary modality of treatment gives better survival.

A prospective evaluation of the sentinel node mapping algorithm in endometrial cancer and correlation of its performance against endometrial cancer risk subtypes.

OBJECTIVE Sentinel node mapping is emerging as the alternative to lymphadenectomy in endometrial cancer. The objective of our study is to validate of the sentinel node mapping surgical algorithm and also to compare the performance of the algorithm against endometrial cancer risk subtypes DESIGN: This is a prospective interventional study carried out at a Single University teaching hospital. All patients with apparent early stage endometrial cancer who underwent robotic assisted surgical staging were included. Intracervical injection of Indocyanine Green dye and sentinel node identification and biopsy was done for all study patients. The node positive rate when using SLN mapping alone versus SLN mapping algorithm were compared. The node positivity was compared against various risk subtypes of endometrial cancer. RESULTS 69 patients were included in the study. In 95.7% patients SLN was detected with a bilateral detection rate of 87.9%. 10 patients had nodal positivity, among which 7 were identified by SLN mapping alone. The algorithm captured all 10 patients with positive LNs, yielding a node positivity rate of 14.9%, sensitivity and NPV of 100%. For SLN mapping alone the sensitivity was 77.8%, false negative rate (FNR) 22.2%, and NPV 96.6%. In low- and intermediate-risk subtypes SLN mapping as well as algorithm identified all node positive patients, but in high-risk endometrial cancers the SLN mapping technique alone had a sensitivity of 57.1% and false-negative rate of 42.9% when compared with 100% sensitivity for the SLN mapping algorithm. CONCLUSIONS When doing SLN mapping and biopsy during endometrial cancer staging surgery it is essential that the steps mentioned in the SLN mapping algorithm are followed as SLN mapping alone seems to have a limitation in detecting positive nodes especially in high risk subtypes of endometrial cancer. Even with the lack of survival data, based on the performance of SLN mapping surgical algorithm (even if ultrastaging facility is not available), it seems to be a better technique in detecting metastatic nodes, giving prognostic information, and enabling accurate adjuvant treatment.

Surgical treatment pattern and outcomes in epithelial ovarian cancer patients from a cancer institute in Kerala, India.

Objective To evaluate the treatment and survival pattern of patients with advanced epithelial ovarian cancer. Methods and results Retrospective study of all advanced epithelial ovarian cancer patients treated in the department of gynaecologic oncology from an academic centre, in a four year period from 1 January 2008–31 December 2011. Selection criteria All patients with advanced epithelial ovarian cancer (stage III and IV) who underwent surgery from 2008–2011and had a follow-up of at least three months after completion of treatment were included. The decision on whether primary surgery or neoadjuvant chemotherapy (NACT) in advanced ovarian cancer was based on age, performance status, clinical and imaging findings. Results A total of 178 cases of epithelial ovarian cancer were operated on during this four year period. Among them 28 patients were recurrent cases, 22 had early stages of ovarian cancer, and the rest 128 had stage III and IV ovarian cancer. In these 128 patients, 50(39.1%) underwent primary surgery and 78(60.9%) had NACT followed by surgery. In the primary surgery group 36(72.0%) patients had optimal debulking while in the NACT group 59(75.6%) patient had optimal debulking. With a median follow-up of 34 months, the median overall survival (OS) and progression free survival (PFS) was 53 and 49 months respectively. Patients who underwent primary surgery had better median PFS than patients who had NACT (56 months versus 39 months, p = 0.002). In stage III C the difference median PFS was significant for those treated with primary surgery when compared with NACT (55 months versus 39 months, p = 0.012). In patients who had optimal debulking to no residual disease (n = 90), primary surgery gave a significant improved PFS (59 months versus 38 months, p = 0.001) when compared with NACT. In univariate analysis, NACT was associated with increased risk of death (HR: 0.350; CI: 0.177–0.693). Conclusion In advanced epithelial ovarian cancer, primary surgery seems to have a definite survival advantage over NACT in patients who can be optimally debulked to no residual disease.

A prospective comparison of perioperative morbidity in advanced epithelial ovarian cancer: Primary versus interval cytoreduction - experience from India.

Objectives: The objective was to compare perioperative morbidity and mortality of patients with advanced epithelial ovarian cancer (EOC) treated with either of the two treatment approaches; neoadjuvant chemotherapy (NACT) followed by interval debulking versus upfront surgery. Design: Prospective comparative observational study. Participants: In total, 51 patients were included in the study. All patients with diagnosed advanced EOC (International Federation of Gynecology and Obstetrics IIIC and IV) presenting for the 1st time were included in the study. Interventions: Patients were either operated upfront (n = 19) if deemed operable or were subjected to NACT followed by interval debulking (n = 32). Primary and Secondary Outcomes: Intra- and postoperative morbidity and mortality were the primary outcome measures. Results: Patients with interval cytoreduction were noted to have significantly lesser operative time, blood loss, and extent of surgery. Their discharge time was also significantly earlier. However, they did not differ from the other group vis. a vis. postoperative complications or mortality. Conclusions: Neoadjuvant chemotherapy although has a positive impact on various intraoperative adverse events, fails to show any impact on immediate postoperative negative outcomes.

A Comparison of the Clinical Outcomes in Uterine Cancer Surgery After the Introduction of Robotic-Assisted Surgery

ObjectiveTo compare the rates of intraoperative and postoperative complications of open and robotic-assisted surgery in the treatment of endometrial cancer.MethodsThis retrospective study was performed at a single academic institution from January 2014 to February 2017 in the Department of Gynecology Oncology at Amrita Institute of Medical Science, Kerala, India. The study included patients with clinically early stage uterine malignancy undergoing open or robotic-assisted surgery. Data collected included clinicopathological factors, intraoperative data, length of hospital stay and intraoperative and postoperative (early and late and severity according to Clavien–Dindo classification). Morbidity was compared between two groups.ResultsThe study included 128 patients, of whom 61 underwent open surgery and 67 underwent robotic-assisted surgery. Mean operative time (P = 0.112), mean estimated blood loss (P < 0.001), number of patients requiring blood transfusion (P < 0.001) and mean length of hospital stay (P < 0.001) were significantly lower in robotic group. None of the patients in robotic group experienced intraoperative hemorrhage (P = 0.010). The early postoperative complications, SSI (P < 0.001), infection (P = 0.002), and urinary complications (P = 0.030) and late postoperative complications lymphoedema (P = 0.002), vault-related complications (1.5% robotic vs. 6.6% open) and incisional hernia (none in robotic vs. 4.9% in open) were significantly lower in robotic group. Grade-II complications (Clavien–Dindo classification) were significantly lower in robotic group (P < 0.001).ConclusionRobotic-assisted surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay.

Undifferentiated Sarcoma of Fallopian Tube Managed with Robotic-Assisted Surgery

A 66-year-old postmenopausal lady presented with a 1-month history of left lower quadrant abdominal pain. On abdominopelvic examination, she was found to have a nontender left adnexal mass with restricted mobility about Dr. Reshu Agarwal is a Fellow, Department of Gynecologic Oncology, Amrita Institute of Medical Sciences; Dr. Anupama Rajanbabu is a Professor, Department of Gynecologic Oncology, Amrita Institute of Medical Sciences; Dr. Indu R. Nair is a Professor, Department of Pathology, Amrita Institute of Medical Sciences.

Endometrial stromal sarcoma-A retropsective analysis of factors affecting recurrence.

OBJECTIVE To assess the factors associated with disease free survival and overall survival in endometrial stromal sarcoma (ESS). METHODS This was a single institution retrospective analysis done at Amrita Institute of Medical Sciences. Records from January 2005 to October 2016 were analysed and 42 patients with ESS were identified. Clinicopathological, surgical management, adjuvant treatment and outcome data were collected. Disease free and overall survivals were analysed using Kaplan-Meier method and compared using log rank test. RESULTS Out of 38 patients included in analysis 28 (73.7%) had low grade ESS (LGESS) and 10 (26.3%) had high grade ESS (HGESS). The median follow up period was 28 months (range 1-110 months). The 5year disease free survival (DFS) and overall survival (OS) for the entire cohort were 62.9 and 89.1% respectively. High grade ESS was significantly associated with recurrence on univariate analysis (p=0.045). Complete staging surgery in both HGESS and LGESS and adjuvant treatment in HGESS and advanced stage LGESS (cohort 1) were associated with improved 5-year DFS of 90.9% (p<0.001). Completion staging surgery in patients with initial incomplete surgery (cohort 3) was associated with improved 5-year DFS of 100% (p<0.001). Complete Staging surgery but no adjuvant treatment in HGESS and advanced stage LGESS (cohort 2) was associated with significantly poor 2-year DFS of 20% (5-year DFS rate 0%; as all patients recurred within 27 months) (P<0.001). Significantly reduced 5-year DFS rate of 25% (p<0.001) was also seen in cases where initial incomplete surgery was not followed by complete staging and adjuvant treatment (cohort 4). Adjuvant treatment in HGESS was associated with improved 5-year DFS of 66.7% (p=0.043). Resection of recurrent lesions were associated with improved mean survival of 41.2 months. CONCLUSION Incomplete surgery and no adjuvant treatment in ESS are associated with poor DFS. Complete staging surgery is associated with improved DFS. Resection of recurrent disease is associated with survival advantage.