Shraddha Patkar

Down-staging following neoadjuvant chemo-radiotherapy for locally advanced rectal cancer: Does timing of surgery really matter?

Background: Neoadjuvant chemoradiotherapy (NACTRT) improves local recurrence rate in locally advanced (LA) rectal cancer with no survival benefit. Pathological complete response (pCR) post-NACTRT is associated with improved outcome. Debate is ongoing as to when would be the opportune time to operate. Aim: To determine if greater down-staging can be achieved by a longer time interval from NACTRT to surgery (tumor regression score [TRS]) and whether this would impact sphincter saving surgery rates and early relapse rates. Materials and Methods: A retrospective analysis of a prospectively maintained database of patients with LA rectal adenocarcinoma treated from January 2012 to August 2013 was carried out. One hundred and ten patients who completed NACTRT (50 Gy/25 fractions with capecitabine 825 mg/m2 twice daily) followed by surgical resection were included. For response evaluation patients were divided into two groups, Group 1 (TRS ≤60 days, n = 42) and 2 (TRS >60 days, n = 68). Tumor down-staging, pCR rate, tumor regression grade (TRG) post-NACTRT and relapse rates were correlated with TRS. Results: Of 110 patients (median age: 49 years (21-73), 71% males; 18 (16.5%) with signet ring histology) 96% patients underwent an R0 resection. Post-NACTRT, CR was attained in 5 (4.5%), partial response in 98 (89%) and stable disease in 7 (6.4%) patients. Median time from completion of NACTRT to surgery was 64.5 days (6-474). Median lymph nodes harvested were 10 (1-50). Overall, 22 (20%) patients achieved pCR. 26 (62%) patients in Group 1 compared to 36 (53%) in Group 2 underwent sphincter sparing surgery (SSS) (P = 0.357). Six patients (14%) in Group 1 and 16 (24%) in Group 2 achieved pCR (P = 0.24). Median TRG in both groups was three. Conclusion: Timing of surgery following NACTRT for LA rectal cancer does not influence pathological response, ability to perform SSS or disease-free survival. There is no incremental benefit of delaying the surgery though this needs to be confirmed in a prospective randomized trial.

Gastrointestinal Neuroectodermal Tumor: a Diagnostic Dilemma

Malignant gastrointestinal neuroectodermal tumor (GNET), a rare soft tissue sarcoma, is a recently described distinct clinicopathological entity. With only a few cases reported in literature till date, there is limited knowledge about the behavior as well as diagnosis of this tumor. GNET mimics several other tumors and hence presents as a diagnostic challenge to clinicians and pathologists alike. We report a case of gastrointestinal neuroectodermal tumors with liver metastasis.

Emerging role of multimodality treatment in gall bladder cancer: Outcomes following 510 consecutive resections in a tertiary referral center

Gall bladder cancer (GBC) is a disease with high incidence in India. We analyzed the outcomes of patients with suspected GBC who underwent surgical exploration.

Treatment of advanced Gall bladder cancer in the real world—can continuation chemotherapy improve outcomes?

BACKGROUND Gemcitabine-Platinum doublet chemotherapy is the standard of care in patients with locally advanced inoperable and metastatic (LA/M) Gall bladder cancers (GBC). METHODS Consecutive patients with LA/M GBC treated with Gemcitabine-Cisplatin (GC) or Gemcitabine-Oxaliplatin (GO) as first line palliative chemotherapy from January 2013 to June 2015 were retrospectively analysed. Patients who were able to continue chemotherapy beyond 6-8 cycles were separately compared to those who were potential candidates for this approach, but chose not to continue chemotherapy. RESULTS A total of 396 patients received first line palliative chemotherapy during the period of analysis, 276 patients (69.6%) were unable to complete 6-8 cycles of chemotherapy, while 120 patients (30.4%) were potential candidates for continuing chemotherapy. Seventy patients (n=120; 58.3%) received a median of 4 cycles of continuation chemotherapy. Median overall survival (OS) for the entire cohort was 7.65 months [95% confidence interval (CI), -7.14 to 8.16], while median event free survival (EFS) was 4.53 months (95% CI, -4.23 to 4.83). Patients receiving continuation chemotherapy had a statistically improved median OS compared to all other patient cohorts, 14.88 months (95% CI, -12.48 to 17.27; P=0.005 on multivariate analysis). Burden/number of sites of metastases, receiving of continuation chemotherapy, fit and able to receive second line chemotherapy (CT2) were identified on multivariate analysis as prognostic factors for OS. CONCLUSIONS OS in our study appeared lower than published literature, but a group of patients were identified whose survival could be prolonged by continuing chemotherapy. Easily available factors can predict prognosis of GBC undergoing first line palliative chemotherapy.

Erratum to: A Case of Ruptured Adult Embryonal Sarcoma of the Liver with Excellent Outcome After Neoadjuvant Chemotherapy

The original version of this article unfortunately contained a mistake. The age of the patient in the first sentence of the first paragraph under the Case Summary section was incorrectly mentioned as 2 years, which is actually 25 years. The sentence should read: A 25-year-old gentleman with no known medical comorbidities presented to his primary physician with complaints of right hypochondriac pain of 2 months duration.

Unusual presentation of melanoma of unknown primary origin: A case report and review of literature

Malignant melanomas often present with metastasis to regional lymph nodes. Patients are also known to present with metastatic nodes in the absence of a known primary. However metastatic melanoma involving the stomach is rare in the scenario of an unknown primary lesion. We present a case of a 41-year-old lady who was treated for nodal disease in the right axilla 8. months earlier with an unknown primary. She later presented to us with a recurrent right axillary swelling and on evaluation was found to also have a nodular deposit on the greater curvature of the stomach. Histopathology of the deposit in conjunction with immunohistochemical markers S.100P, Melan-A and HMB-45, confirmed the diagnosis of malignant melanoma. The patient underwent surgical excision of both lesions and is now on regular follow-up.

Solitary fibrous tumor of the liver - An unusual entity: A case report and review of literature

Solitary fibrous tumor (SFT) of the liver is a rare entity and its presentation is usually delayed till they grow to a substantial size. Clinico-radiological features are non-specific, contributing to increase in the diagnostic dilemma. Definitive diagnosis of SFT is usually made based on the histological features and immunohistochemistry data of the resected specimen. In this case report, we describe the case of an elderly male who presented with a large mass in the left lobe of the liver with normal level of tumor markers and atypical radiological findings. The patient successfully underwent resection of the tumor and the diagnosis was confirmed on histopathology.

Extracapsular excision of hepatic hemangioma: A single centre experience

Backgrounds/Aims Hepatic hemangioma is a common non-epithelial neoplasm of the liver. Presence of symptoms and uncertainty in diagnosis are the most common indications for surgery. Methods Eighteen patients with hepatic hemangioma, operated on from January 2011 to December 2016 at the Hepato-pancreato-biliary surgical unit of Tata Memorial Hospital, were retrospectively analyzed. Results Main indications for operation were presence of symptoms, the most common being pain and diagnostic uncertainty. The median size of hemangioma was 9.9 cm (range 3.2 to 24 cm). All patients underwent extra-capsular excision of hemangioma. The median operating time was 180 minutes (range 75 to 460 minutes) and median blood loss was 950 ml (range 100 to 3,500 ml). Median post-operative stay was 5.5 days (range 3 to 10 days). One (5.6%) patient required re-exploration for post-operative hemorrhage, Clavien Dindo (CD) grade IIIb, and one (5.6%) had postoperative purulent intra-abdominal collection requiring percutaneous cutaneous drainage CD grade IIIa. There was no postoperative mortality. Postoperative day 3 liver function tests were within normal limits. Size of the tumor did not correlate significantly with postoperative complications (p=0.135). Conclusions Surgical treatment of hemangioma should be guided by presence of symptoms or by the presence of diagnostic uncertainty, not by size alone. The size had no correlation with perioperative complications. The technique of extra-capsular excision is safe and technically feasible in most of the hemangiomas. This technique preserves maximum liver parenchyma, resulting in early postoperative recovery with minimal morbidity.

Tolerance and adverse event profile with sorafenib in Indian patients with advanced hepatocellular carcinoma

Background: The current standard of treatment for advanced hepatocellular cancer Hepatocellular carcinoma (HCC) is Sorafenib. Data regarding its tolerance and adverse event profile in Indian patients is scarce. Materials and Methods: The primary aim of this analysis was to assess the adverse events (Grade 3 and Grade 4 as per CTCAE v4.0) and requirements for dose reduction with sorafenib in advanced HCC. Details of consecutive patients started on 800 mg/day dosing were obtained from a prospectively maintained database (over a period of 6 months) and analyzed. Results: Thirty-nine patients were available for inclusion in the study. Median age was 58 years (range: 20–75). All patients were classified as Barcelona clinic liver cancer C. Common side effects seen were liver dysfunction (38.5%), hand-foot-syndrome-rash (HFSR) (Grade 2 and 3-25.6%), fatigue (Grade 2 and Grade 3–10.3%), and diarrhea (7.7%). Dose reduction was required in 43.6% of patients. Drug interruptions/cessation was required in 38.5% of patients within the first four months of treatment. Nearly 41% of patients required cessation of sorafenib due to intolerable side-effects while 28.2% stopped sorafenib due to progressive disease. At a median follow-up of 4.9 months, median event-free survival (EFS) was 4.20 months (95% confidence interval: 3.343–5.068). Conclusion: A higher incidence of liver dysfunction and HFSR is seen in Indian patients as compared to published data. A significant proportion of patients required cessation of sorafenib due to adverse events in our series. However, EFS remains on par with that seen in larger studies with sorafenib in advanced HCC.

Metastasis from Hepatocellular Carcinoma Masquerading as a Jugular Paraganglioma

Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver. It is the sixth most common cancer in the world, with 782,000 new cases occurring in 2012 worldwide. In 2012, there were 746,000 deaths from liver cancer [1]. HCC is the third most fatal cancer in the world [2]. Hepatocellular carcinoma commonly metastasizes to the lungs, abdominal lymph nodes, adrenal glands, or bones [3]. Distant lymph node metastases are rare in hepatocellular carcinoma. We present an unusual case of HCC with isolated metastasis to temporal bone in the absence of metastatic disease elsewhere which resulted in change in management from a surgically resectable temporal lesion to a palliative therapy for metastatic disease.