Arun Chaturvedi

Carcinoma of the gallbladder

Carcinoma of the gallbladder is the most common malignant tumour of the biliary tract and a particularly high incidence is observed in Chile, Japan, and northern India. The aetiology of this tumour is complex, but there is a strong association with gallstones. Owing to its non-specific symptoms, gallbladder carcinoma is generally diagnosed late in the disease course, but if a patient with gallstones experiences a sudden change of symptoms, then a cancer diagnosis should be considered. Treatment with radical or extended cholecystectomy is potentially curative, although these procedures are only possible in 10-30% of patients. There is no role for cytoreductive surgery in this disease. If a gallbladder carcinoma is discovered via pathological examination of tissue samples, then the patient should be examined further and should have radical surgery if the tumour is found to be T1b or beyond. Additional port-site excision is necessary if the patient has already had their gallbladder removed during laparoscopy; however, patients with an intact gallbladder who are suspected to have gallbladder carcinoma should not undergo laparoscopic cholecystectomy. Patients with advanced inoperable disease should receive palliative treatment; however, the role of chemotherapy and radiation in these patients needs further evaluation.

Penile carcinoma: a challenge for the developing World

Although rare in developed countries, carcinoma of the penis is an important problem in the developing world. Circumcision done in childhood offers the greatest protection against this disease. Poor penile hygiene and phimosis are strong risk factors for development of penile carcinoma. Early disease can be treated by conventional resection of the penis, or in selected patients by organ preserving techniques including Mohs micrographic surgery, and laser and radiation therapy. For more advanced primary disease, partial or total penectomy is needed. Elective or therapeutic lymph-node dissection is recommended for inguinal metastatic disease, and depending on the disease status, unilateral or bilateral inguinal or ilioinguinal lymphadenectomy might be needed. The role of chemotherapy, as adjuvant or primary treatment in metastatic disease, needs to be defined in prospective clinical trials, which can be done in developing countries.

Management of Gingivobuccal Complex Cancer

INTRODUCTION Squamous cell carcinoma of the oral cavity ranks as the 12th most common cancer in the world and the 8th most frequent in males. It accounts for up to one-third of all tobacco-related cancers in India. Cancer of the gingivobuccal complex is especially common in Indians due to their tobacco habits. This review focuses on the management of lower gingivobuccal complex cancers. PATIENTS AND METHODS References for this review were identified by search of Medline and other bibliographic information available in the PubMed database. The search terms carcinoma oral cavity, and cancer oral cavity, buccal mucosa, gingiva, gingivobuccal complex, and alveolus cancer/carcinoma were used. References from relevant articles and abstracts from international conferences were also included. Only articles published in the English language were used. RESULTS Treatment of gingivobuccal complex cancer is primarily surgical. Radical neck dissection, or its modification, is the standard treatment for the node-positive neck. Supraomohyoid neck dissection is the accepted treatment for the node-negative neck. Radiotherapy is usually not the preferred modality of treatment for early gingivobuccal complex cancer. It is used either as postoperative adjuvant treatment or as definitive treatment for advanced cancer with or without chemotherapy. Chemotherapy has been used as neo-adjuvant, adjuvant or palliative treatment. Advanced cancers are common and continue to pose a challenge to the multidisciplinary team. CONCLUSIONS Gingivobuccal complex cancer remains a major public health problem despite being highly preventable and easily detectable. Advanced cancers constitute a major proportion of patients presenting for treatment. These patients are difficult to treat and have a poor outcome.

Development of a New Outcome Prediction Model in Early-stage Squamous Cell Carcinoma of the Oral Cavity Based on Histopathologic Parameters With Multivariate Analysis: The Aditi-Nuzhat Lymph-node Prediction Score (ANLPS) System

The aim of this study was to evaluate the histopathologic parameters that predict lymph node metastasis in patients with oral squamous cell carcinoma (OSCC) and to design a new assessment score on the basis of these parameters that could ultimately allow for changes in treatment decisions or aid clinicians in deciding whether there is a need for close follow-up or to perform early lymph node dissection. Histopathologic parameters of 336 cases of OSCC with stage cT1/T2 N0M0 disease were analyzed. The location of the tumor and the type of surgery used for the management of the tumor were recorded for all patients. The parameters, including T stage, grading of tumor, tumor budding, tumor thickness, depth of invasion, shape of tumor nest, lymphoid response at tumor-host interface and pattern of invasion, eosinophilic reaction, foreign-body giant cell reaction, lymphovascular invasion, and perineural invasion, were examined. Ninety-two patients had metastasis in lymph nodes. On univariate and multivariate analysis, independent variables for predicting lymph node metastasis in descending order were depth of invasion (P=0.003), pattern of invasion (P=0.007), perineural invasion (P=0.014), grade (P=0.028), lymphovascular invasion (P=0.038), lymphoid response (P=0.037), and tumor budding (P=0.039). We designed a scoring system on the basis of these statistical results and tested it. Cases with scores ranging from 7 to 11, 12 to 16, and ≥17 points showed LN metastasis in 6.4%, 22.8%, and 77.1% of cases, respectively. The difference between these 3 groups in relation to nodal metastasis was very significant (P<0.0001). A patient at low risk for lymph node metastasis (score, 7 to 11) had a 5-year survival of 93%, moderate-risk patients (score, 12 to 16) had a 5-year survival of 67%, and high-risk patients (score, 17 to 21) had a 5-year survival of 39%. The risk of lymph node metastasis in OSCC is influenced by many histologic parameters that are not routinely analyzed in pathologic reports. These significant independent factors were graded to design a scoring system that permits accurate evaluation of the risk of metastasis with accuracy independent of the traditional TNM system or isolated histologic parameters. The need for neck node dissection can be predicted depending upon the scores obtained.

Global epidemiological trends and variations in the burden of gallbladder cancer

The aim of this study is to describe the trends and variations in the global burden of gallbladder cancer (GBC) with an emphasis on geographic variations and female gender.

Retroperitoneal Sarcomas- A Challenging Problem

Retroperitoneal sarcomas are relatively rare tumours and usually present in a locally advanced stage. Liposarcoma is the most common histopathology. If operable, surgery is the treatment of choice. The role of adjuvant chemotherapy or radiotherapy is not yet defined. Advanced cases are treated by chemotherapy. The prognosis is poor in patients with positive resection margins, high-grade tumours and recurrent tumours.

Vascular endothelial growth factor expression in oral cancer and its role as a predictive marker: A prospective study

Background: Oral cancer is one of the common cancers in India with dismal survival in advanced stages. Most of the patients present in advanced stages with borderline operability and such patients may be helped by chemotherapy to render them operable. It is well known that tumor growth is angiogenesis-dependent and thus vascular endothelial growth factor (VEGF) may be a surrogate marker of growth and angiogenesis. At present, there is a scarcity of predictive markers for oral cancer. In this prospective study, we studied VEGF expression and its role as a predictive marker in oral cancer. Materials and Methods: Patients with locally advanced oral cancer having borderline operability or unfit to undergo surgery in the primary setting were included in the study. VEGF expression of the cancerous tissue was studied in all patients. Three cycles of neoadjuvant chemotherapy (NACT) was administered before definitive treatment in locally advanced cases and response is assessed. VEGF levels were analyzed in cancer tissue and compared with normal surrounding mucosa. The response to chemotherapy was then correlated with VEGF score in patients receiving NACT to evaluate it as a predictive marker. Results: All forty patients were VEGF-positive and had a mean score of 1023 with 63% patients having Grade 3 expressions, whereas the normal surrounding mucosa had a VEGF score of 30. It was seen that in patients showing no response to treatment, the mean total VEGF score was significantly higher as compared to those showing complete or partial response. VEGF score correlated inversely with chemotherapy response, but no significant association was seen between VEGF grade and chemotherapy response. Conclusion: We can conclude from this study that VEGF is significantly overexpressed in cancer mucosa as compared to normal mucosa and overexpression of VEGF was found to be associated with chemoresistance and thus may serve as a negative predictive marker.

Clinical relevance of PD-L1 expression in gallbladder cancer: a potential target for therapy.

Programmed death‐ligand 1 (PD‐L1), a potential target for immune checkpoint inhibitors in various solid neoplasms, has been studied in very few cases of Gall Bladder Carcinoma (GBC). The current study aimed to evaluate PD‐L1 expression at primary and metastatic sites of GBC, and its associations with standard prognostic clinicopathological parameters, as well as with overall survival.

Penile Sarcoma: Report of a Rare Malignancy

Penile cancer is an uncommon malignancy. Squamous cell carcinoma constitutes approximately 95% of all histology. Non-squamous malignancies are rare in penis. Sarcomas of penis are rarer among them. Spindle cell sarcoma is one of the extremely rare sarcoma of penis. To best of our knowledge, only two cases have been reported so far, one in English literature and other in Japanese. We are presenting this uncommon case of spindle cell sarcoma of penis, which was diagnosed with microscopy with its characteristic immunohistochemistry. The disease had an aggressive course with multiple recurrences in a short duration despite margin negative resection. Disease responded poorly with the chemotherapy and patient succumbed to the disease.

Cancer surgery: an Indian-Asian perspective

www.thelancet.com/oncology Vol 16 September 2015 1189 Cancer surgery is an integral part of the multimodal management of solid cancers and has a central role in the treatment of several common cancers in Asian countries. As stressed in The Lancet Oncology Commission on global cancer surgery, there is a need for surgery—curative or palliative—in over 80% of patients with cancer. Providing safe, aff ordable, and timely surgery for cancer is a complex task. It involves health-care policy, training and education, management and delivery of health care, fi nance, social, and economic issues. Many of the general principles for providing safe surgery—described in The Lancet Commission on global surgery—apply also to cancer surgery. The diffi culty for economically constrained low-income and middle-income countries (LMICs) in Asia is to fi nd resources to fund and manage the infrastructure and manpower needed to achieve this task. Some of the unique diffi culties faced in countries such as India and China are the many alternative and traditional systems of medicine available. In India, a large proportion of the population is illiterate and not knowledgeable about health care and tends to opt for easy (eg, non-invasive treatments requiring no investigations or waiting, with minimum side-eff ects and few functional and cosmetic problems) and less expensive methods of treatment. These unproven methods of treatment result in delays and disease progression, and the potential curative role of surgery may be lost. The government policy of promoting alternative and traditional systems of medicine only worsens this situation. Myths and prejudice against surgery and surgical interventions for cancer also exist, which drives patients to seek inappropriate non-surgical treatments. Finally, when these patients reach the cancer surgeon, they have advanced unresectable disease and surgical interventions are doomed to fail. In India, the National Cancer Control Programme has been in place for almost four decades. However, this programme ignores the need for cancer surgery and places strong emphasis on providing infrastructure for radiotherapy alone. No concerted eff ort has been made to develop surgical oncology as a specialty, and there is a major shortage of trained cancer surgeons. Few surgical oncology training opportunities are available at present. In the absence of formal guidelines, general surgeons, who might have a limited understanding and ability of cancer surgery, perform most of the surgery for patients with cancer. Incomplete and inadequate primary surgery further complicates the management of these patients. Finances for cancer surgery, in the absence of health insurance, remain an out-of-pocket expenditure by patients. In India, to some extent, government hospitals provide cancer surgery at a subsidised cost or fund the management of patients who are below the poverty line. However, these facilities are not available in all places, and a large inequality exists in the aff ordability and quality of cancer care, including cancer surgery, in India. Major infrastructure defi ciencies also exist. Highquality pathology, imaging, safe anaesthesia, and ancillary specialties (eg, reconstructive surgery) are scarce. Quality cancer care is available in only a handful of government institutions and a rapidly expanding group of private or corporate hospitals. Most patients with cancer cannot aff ord treatment in these exclusive hospitals. The absence of a standardised referral system Cancer surgery: an Indian-Asian perspective timely, and safe interventions with the aim of achieving cost-eff ective global technological advances. Laproscopes and robots do not operate, surgeons do.