A comparative study of indocyanine green instillation in inguinal node versus foot web space using da Vinci indocyanine green FireFly™ technology in identifying thoracic duct during robotic-assisted transthoracic oesophagectomy

INTRODUCTION

Chyle leak is a serious complication following oesophagectomy with incidence varies from 1% to 9%. Near infra-red fluorescence imaging of thoracic duct (TD) can provide real-time dynamic imaging during the surgery. In this study, we intend to compare indocyanine green (ICG) dye instillation through inguinal node with subcutaneous first web space instillation for visualisation of TD during robotic-assisted minimally invasive oesophagectomy (RAMIE) procedure.

PATIENTS AND METHODS

A prospective study of 50 patients underwent RAMIE with da Vinci X System. After general anaesthesia, patients were divided into inguinal node and foot first web space ICG instillation group. The former group had 1 ml of ICG dye instilled on bilateral inguinal nodes under ultrasound guidance and while the other group received 1 mL of ICG dye injected at bilateral foot first web space and then underwent surgery. TD was visualised using ICG FireFly™ fluorescence technology, first at the time of docking and subsequently for every 5 min until 60 min of instillation time and analysed.

RESULTS

Twenty-five patients were enrolled in each group. The mean docking time for thoracic phase was 13.76 ± 3.43 min. TD was visualised in 72% (18/25) of cases of first web space instillation group, whereas 100% in ultrasound guidance inguinal node instillation group. None of the patients had a chyle leak.

CONCLUSION

ICG FireFly™ fluorescence technology for the identification of TD during oesophageal mobilisation is safe and effective and provides real-time dynamic visualisation with high accuracy in ultrasound-guided bilateral inguinal node instillation group. It is an effective method for the surgeons planning to negotiate their initial learning curve in RAMIE procedures.

Prospective analysis of impact of learning curve in robotic-assisted rectal surgery in the high-volume Indian tertiary care centre

Background

Minimally invasive surgery in rectal cancer has gained prominence owing to its various advantages in surgical outcomes. Due to rapid adoption of robotics in rectal surgery, we intended to assess the pace in which surgeons gain proficiency using cumulative summation (CUSUM) technique in learning curve.

Materials and Methods

This was a prospective study of 262 rectal cancer cases who underwent robotic-assisted low anterior resection and abdominoperineal resection (RA-LAR and RA-APR). Parameters considered for the study were console time, docking time, lymph nodal yield, total operative time and post-operative outcomes. We used Manipal technique of port placements and modified centroside docking for the procedure.

Results

The mean age of our study was 46.62 ± 5.7 years, the mean body mass index (BMI) was 31.51 ± 3.2 kg/m2. 215 (82.06%) underwent RA-LAR and 47 (17.93%) underwent RA-APR. 2.67% of cases required to open during our initial period. We had three phases of learning curve, initial phase (11th case), plateau phase (29th case) and then phases of mastery (30th case onwards). Our mean total operative time reduced from 5.5 to 3.5 h (210 ± 8.2 min), console time from 4.5 to 2.9 h (174 ± 4.5 min) and docking time from 15 to 9 ± 1 min from 30th case onwards.

Conclusion

RA surgeries for rectal cancer have got good oncological and functional outcomes in high BMI, male pelvis and low rectal cancers. Learning curve can be shortened with constant self-auditing of the surgeon and team with each surgeries performed, reviewing the steps and by improving techniques.

Consensus guidelines for the management of HR-positive HER2/neu negative early breast cancer in India, SAARC region and other LMIC by DELPHI survey method

BACKGROUND

Precise prognostication is the key to optimum and effective treatment planning for early-stage hormone receptor (HR) positive, HER2/neu negative breast cancer patients. Differences in the breast cancer incidence and tumor anatomical features at diagnosis, pharmacogenomics data between Western and Indian women along with the vast diversity in the economic status and differences in insurance policies of these regions; suggest recommendations put forward for Western women might not be applicable to Indian/Asian women. Opinions from oncologists through a voting survey on various prognostic factors/tools to be considered for planning adjuvant therapy are consolidated in this report for the benefit of oncologists of the sub-continent, SAARC and Asia's LMIC (low and middle-income countries).

METHODS

A three-phase DELPHI survey was conducted to collect opinions on prognostic factors considered for planning adjuvant therapy in early-stage HR+/HER2/neu negative breast cancer patients. A panel of 25 oncologists with expertise in breast cancer participated in the survey conducted in 2021. The experts provided opinions as 'agree' or disagree' or 'not sure' in phases-1 and 2 which were conducted virtually; in the final phase-3, all the panel experts met in person and concluded the survey.

RESULTS

Opinions on 41 statements related to prognostic factors/tools and their implications in planning adjuvant endocrine/chemotherapy were collected. All the statements were supported by the latest data from the clinical trials (prospective/retrospective). The statements with opinions of consensus less than 66% were disseminated in phase-2, and later in phase-3 with supporting literature. In phase-3, all the opinions from panelists were consolidated and guidelines were framed.

CONCLUSIONS

This consensus guideline will assist oncologists of India, SAARC and LMIC countries in informed clinical decision-making on adjuvant treatment in early HR+/HER2/neu negative breast cancer patients.

Prospective analysis of 164 fires of da Vinci SureForm SmartFire stapler in oncological cases: Indian cohort of 76 consecutive cases

Background

The application of robotic staplers in surgeries has increased in recent years. Robotic platform enhances ability of the surgeon to directly control and manoeuvre staplers to achieve required angulation and sealing within the confines of the thorax and pelvis. Hence, in this study, we intended to learn the effectiveness of the SureForm™ SmartFire™ technology stapling system in various oncological procedures.

Patients and Methods

Prospective study of 76 patients who underwent robotic-assisted total oesophagectomy, gastrectomies, hemicolectomies, low anterior resection/abdominoperineal resection and lobectomies/metastasectomy for respective malignancies for 16 months. Internal data log of the da Vinci surgical system for reload colour, reloads used, clamp attempts and staple fires used during each procedure along with patient's post-operative outcomes were recorded.

Results

One hundred and sixty-four firings have been made in 76 cases, with the majority being green reloads (76.8%) and average reloads for radical cystectomy 3.5, lobectomies/metastasectomy 3.44 and oesophagectomy 2.55. None of the cases had incomplete firings and required force-fire activation. In forty per cent of cases, the robotic stapler had to pause for sequential compression and seal. Seventy per cent of anterior resection procedures had at least one firing >45° beyond the laparoscopy limit. Collectively 52% SureForm stapler fires in anterior resection with >45° angle of fire. None of the cases had bleed or leak.

Conclusion

SureForm™ SmartFire™ robotic staplers can be used for various oncological surgeries with minimal peri-operative leak and bleeding and has better articulation in closed spaces. Further case-matched comparative studies with laparoscopic or handheld powered staplers would be required for useful operative decision-making and analyse the clinical outcomes.

Cytoreductive Surgery with HIPEC as Primary Treatment for Advanced Epithelial Ovarian Carcinoma: Upfront or Interval-ISPSM Collaborative Study

Cytoreductive surgery with HIPEC has shown promising results in the interval setting of advanced epithelial ovarian cancer. Its role in upfront setting has not yet been established. All eligible patients underwent CRS-HIPEC as per institution protocol. Relevant data was collected prospectively in institutional HIPEC registry and analyzed retrospectively for the study period from February 2014 to February 2020. Out of 190 patients, 80 underwent CRS-HIPEC in upfront setting and 110 in interval setting. The median age was 54 ± 7.45 years, upfront group had higher PCI (14.1 ± 8.75 vs. 9.6 ± 5.2. 2), and required longer duration of surgery (10.6 ± 1.73 vs. 8.4 ± 1.71 h) had more blood loss (1025 ± 668.76 vs. 680 ± 302.23 ml). The upfront group required more diaphragmatic resections, bowel resections, and multivisceral resections. The overall G3-G4 morbidity was comparable (25.4% vs. 27.3%), upfront group had more surgical morbidity (20% vs. 9.1%) whereas interval group had more medical morbidity, i.e., electrolyte imbalance and hematological. After a median follow-up of 43 months, median DFS was 33 months in the upfront vs. 30 months in the interval group, p = 0.75, median OS was 46 months interval group and was not yet achieved in upfront group.(p = 0.13). Four-year OS was 85% vs. 60%. In patients of advanced EOC upfront CRS HIPEC showed promising outcomes and trend towards better survival with similar morbidity and mortality. The upfront group had more surgical morbidity whereas interval group had more medical morbidity. Multiinstitutional randomized studies are needed to define patient selection and study morbidity patterns and compare the outcomes between CRS-HIPEC in the upfront and interval setting for advanced epithelial ovarian cancer.

Navigating patient journey in early diagnosis of lung cancer in India

Lung cancer (LC) is one of the leading causes of cancer deaths worldwide. In India, the incidence of LC is increasing rapidly, and a majority of the patients are diagnosed at advanced stages of the disease when treatment is less likely to be effective. Recent therapeutic developments have significantly improved survival outcomes in patients with LC. Prompt specialist referral remains critical for early diagnosis for improved patient survival. In the Indian scenario, distinguishing LC from benign and endemic medical conditions such as tuberculosis can pose a challenge. Hence, awareness regarding the red flags-signs and symptoms that warrant further investigations and referral-is vital. This review is an effort toward encouraging general physicians to maintain a high index of clinical suspicion for those at risk of developing LC and assisting them in refering patients with concerning symptoms to specialists or multidisciplinary teams as early as possible.

Treatment Response After Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) for Peritoneal Metastases of Colorectal Originf

The objective of this study is to analyze oncological outcomes of patients with peritoneal metastases (PM) of colorectal origin treated with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC).

Background

PIPAC has been demonstrated to be a feasible and safe novel treatment for patients with PM of various origins. Only small series reports on survival after PIPAC by disease entity.

Methods

International retrospective cohort study of consecutive patients with PM of colorectal origin. Outcome measures were overall survival (OS), radiological response according to Response Evaluation Criteria in Solid Tumors (RECIST), histological response (peritoneal regression grading score [PRGS]: complete response: 1-4: no response), change of peritoneal cancer index (PCI), and symptom control.

Results

Seventeen eligible centers compiled 256 non-selected patients (mean age 61 [50.6-69.2], 43% female) and 606 procedures. Sixty-three percent were treated after 2 lines of chemotherapy, median PCI at PIPAC1 was 18 (interquartile range [IQR] = 10-27). Median OS was 19.00 months (IQR = 12.9-29.8) from diagnosis and 9.4 months (IQR = 4.5-16.8) from PIPAC1. One hundred and four of 256 patients (40.6%) had ≥3 procedures (per protocol [pp]) with the following outcomes at PIPAC3: RECIST: 59.3% partial response/stable, 40.7% progression; mean PRGS: 2.1 ± 0.9. Median PCI was 21 (IQR = 15-29) at baseline and 20 (IQR = 12-27) at PIPAC3 (P = 0.02). Fifty-six (54%) and 48 (46%) patients were symptomatic at baseline and PIPAC3, respectively (P = 0.267). Median OS for the pp cohort was 11.9 months (IQR = 10.7-15.0) from PIPAC1. Independent predictors for survival were radiological response (HR = 3.0; 95% CI = 1.6-5.7) and no symptoms (HR = 4.5, 95% CI = 2.2-9.1) at PIPAC3.

Conclusions

Objective treatment response and encouraging survival were demonstrated after PIPAC for colorectal PM. Prospective registry data and comparative studies are now needed in to confirm these data.

Assessment of Treatment Response after Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC) for Appendiceal Peritoneal Metastases

Background The aim of this study was to analyse survival and surrogates for oncological response after PIPAC for appendiceal tumours. Methods This retrospective cohort study included consecutive patients with appendiceal peritoneal metastases (PM) treated in experienced PIPAC centers. Primary outcome measure was overall survival (OS) from the date of diagnosis of PM and from the start of PIPAC. Predefined secondary outcome included radiological response (RECIST criteria), repeat laparoscopy and peritoneal cancer index (PCI), histological response assessed by the Peritoneal regression grading system (PRGS) and clinical response. Results Final analysis included 77 consecutive patients (208 PIPAC procedures) from 15 centres. Median OS was 30 months (23.00-46.00) from time of diagnosis and 19 months (13.00-28.00) from start of PIPAC. 35/77 patients (45%) had ≥3 procedures (pp: per protocol). Objective response at PIPAC3 was as follows: RECIST: complete response 4 (11.4%), 11 (31.4%) partial/stable; mean PRGS at PIPAC3: 1.8 ± 0.9. Median PCI: 21 (IQR 18-27) vs. 22 (IQR 17-28) at baseline (p = 0.59); 21 (60%) and 18 (51%) patients were symptomatic at baseline and PIPAC3, respectively (p = 0.873). Median OS in the pp cohort was 22.00 months (19.00-NA) from 1st PIPAC. Conclusion Patients with PM of appendiceal origin had objective treatment response after PIPAC and encouraging survival curves call for further prospective evaluation.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer

Introduction

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

Methods

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

Results

Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework.

Conclusion

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey

Purpose

To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers.

Methods

A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era.

Results

There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase.

Conclusion

Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02675-6.

Consensus statement for treatment protocols in pressurized intraperitoneal aerosol chemotherapy (PIPAC)

Objectives

Safe implementation and thorough evaluation of new treatments require prospective data monitoring and standardization of treatments. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a promising alternative for the treatment of patients with peritoneal disease with an increasing number of suggested drug regimens. The aim was to reach expert consensus on current PIPAC treatment protocols and to define the most important research topics.

Methods

The expert panel included the most active PIPAC centers, organizers of PIPAC courses and principal investigators of prospective studies on PIPAC. A comprehensive literature review served as base for a two-day hybrid consensus meeting which was accompanied by a modified three-round Delphi process. Consensus bar was set at 70% for combined (strong and weak) positive or negative votes according to GRADE. Research questions were prioritized from 0 to 10 (highest importance).

Results

Twenty-two out of 26 invited experts completed the entire consensus process. Consensus was reached for 10/10 final questions. The combination of doxorubicin (2.1 mg/m²) and cisplatin (10.5 mg/m²) was endorsed by 20/22 experts (90.9%). 16/22 (72.7%) supported oxaliplatin at 120 with potential reduction to 90 mg/m² (frail patients), and 77.2% suggested PIPAC-Ox in combination with 5-FU. Mitomycin-C and Nab-paclitaxel were favoured as alternative regimens. The most important research questions concerned PIPAC conditions (n=3), standard (n=4) and alternative regimens (n=5) and efficacy of PIPAC treatment (n=2); 8/14 were given a priority of ≥8/10.

Conclusions

The current consensus should help to limit heterogeneity of treatment protocols but underlines the utmost importance of further research.

Real-World Experience with Nivolumab in Metastatic Renal Cell Carcinoma Patients Who Have Progressed on Prior Therapies: A Single-Center Study from India

Introduction Nivolumab monotherapy is approved for the treatment of metastatic renal cell carcinoma (mRCC) patients who have progressed on prior therapies based on the pivotal Checkmate-025 trial. There is limited literature on the efficacy and safety profile of usage of nivolumab in the treatment of mRCC in India in a real-world setting.

Methods A retrospective analysis was performed of patients who received nivolumab monotherapy for mRCC after having progressed on prior therapies. Tumor response was graded according to RECIST v1.1 and Kaplan–Meier survival analysis was used to estimate progression-free survival (PFS) and overall survival (OS). Immune-related adverse events (irAEs) were documented and graded according to CTCAE v5.0.

Results Between 2016 and 2019, 35 patients received nivolumab for mRCC at our center after progression on prior therapies. A majority of the patients (n = 30, 85.7%) received it in a second-line setting, and the remaining in the third line and beyond setting. Clear cell was the most common histology (n = 26, 74.3%). There were 18 patients (51.42%) who belonged to IMDC intermediate risk, while 17 (48.58%) patients were at poor risk. The overall response rate was 60%, with complete response (CR) in 11.4%. Median duration of response was not reached among responders. Median PFS was 5 months (95% confidence interval [CI]: 3.06–6.93) and median OS was 26 months (95% CI: 1.90–50.09). Ongoing survival of 47, 42, 34, and 22 months was noted in four patients with CR, respectively. In our study, 23 patients (65.71%) experienced any grade of irAE. Grade 3 irAEs was seen in four patients (11.42%). Most common irAE was thyroid dysfunction seen in 12 patients (34.2%). Treatment discontinuation due to irAEs occurred in three patients (8.57%).

Conclusion Nivolumab showed good efficacy with high response rates and an OS comparable to the pivotal Checkmate-025 trial. It was well tolerated with safety profile in terms of irAE consistent with those reported in literature.

Practical Consensus Recommendations for Optimizing Risk versus Benefit of Chemotherapy in Patients with HR Positive Her2 Negative Early Breast Cancer in India

Breast cancer is a public health challenge globally as well as in India. Improving outcome and cure requires appropriate biomarker testing to assign risk and plan treatment. Because it is documented that significant ethnic and geographical variations in biological and genetic features exist worldwide, such biomarkers need to be validated and approved by authorities in the region where these are intended to be used. The use of western guidelines, appropriate for the Caucasian population, can lead to inappropriate overtreatment or undertreatment in Asia and India. A virtual meeting of domain experts discussed the published literature, real-world practical experience, and results of opinion poll involving 185 oncologists treating breast cancer across 58 cities of India. They arrived at a practical consensus recommendation statement to guide community oncologists in the management of hormone positive (HR-positive) Her2-negative early breast cancer (EBC). India has a majority (about 50%) of breast cancer patients who are diagnosed in the premenopausal stage (less than 50 years of age). The only currently available predictive test for HR-positive Her2-negative EBC that has been validated in Indian patients is CanAssist Breast. If this test gives a score indicative of low risk (< 15.5), adjuvant chemotherapy will not increase the chance of metastasis-free survival and should not be given. This is applicable even during the ongoing COVID-19 pandemic.

Reaching the women with the greatest needs: Two models for initiation and scale-up of gynecologic oncology fellowship trainings in low-resource settings

Women in low- and middle-income countries (LMICs) are significantly more likely to develop and die from invasive cervical cancer, while rates of other gynecologic malignancies are comparable to those faced by women in high-income countries. Despite this increased need, there are few specialist physicians in LMICs available to treat women with gynecologic cancers. Training specialists in low-resource settings faces multiple challenges, including ensuring protected time from other clinical demands, access to best practice guidelines, training that is tailored to the specific challenges faced in the trainee's environment, and isolation from other fully trained professionals and securing support services. In addition, training specialists from LMICs in high-resource settings is costly and return of trainees to their own country is not guaranteed. Here we describe two approaches to gynecologic oncology training in LMICs. The International Gynecologic Cancer Society (IGCS) developed the Global Curriculum Mentorship and Training Program (Global Curriculum) to support gynecologic oncology fellowships in regions of the world that do not currently have formal training in gynecologic oncology. In India, on the other hand, leaders in world-class gynecologic oncology centers must find a way to meet the training needs of a vast and disparate country.

Bowel Anastomosis After or Before HIPEC: A Comparative Study in Patients Undergoing CRS+HIPEC for Peritoneal Surface Malignancy

BACKGROUND

Anastomotic leak after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. There is no consensus statement regarding the optimal timing for bowel anastomoses to perform after or before HIPEC.

METHODS

Patients who underwent CRS+HIPEC and had at least one bowel anastomosis were retrospectively analyzed to evaluate if timing of anastomosis done after or before HIPEC had an impact on bowel complication rates (anastomotic leak and perforation).

RESULTS

From 2013 to 2019, 214 of 370 patients underwent CRS+HIPEC and had at least one bowel anastomosis. Of these 214 patients, 104 and 110 patients had anastomosis after and before HIPEC, respectively. A total of 324 anastomoses were performed, with a mean of 0.87 anastomoses per patient (range 1-4). The incidence of anastomotic leaks was comparable between the pre- and post-HIPEC groups (3.6% vs. 4.8%; p > 0.05), as was the bowel complication rate (7.6% vs. 7.2%). After multivariate analysis, prior surgical score >1 (odds ratio [OR] 4.3), recurrent cancers (OR 7.4), and more than two anastomosis (OR 3.8) were considered independent risk factors for bowel complications.

CONCLUSION

Anastomosis of the bowel performed after or before HIPEC does not affect bowel complication rates (leak/perforation). Higher prior surgical score, surgery for recurrent cancers, and more than two bowel anastomosis are independent risk factors for predicting bowel complications. Prehabilitation, standardization of steps, immediate attention and repair of serosal tears, and thorough inspection of the bowel before closure helps to decrease bowel complications. The timing of anastomosis can be at the discretion of the surgeon.

South Asian Declaration-Consensus Guidelines for COVID-19 Vaccination in Cancer Patients

We provide the South Asian Declaration, containing the consensus guidelines for coronavirus disease 2019 (COVID-19) vaccination in cancer patients.

Robust Protective Effect of COVID-19 Vaccination in India-Results of Survey in the Midst of Pandemic's Second Wave

Introduction  Our objective was to document the incidence of COVID-19 in vaccinated health care professionals and related personnel.

Method  We conducted an online survey to ascertain the incidence of COVID-19 symptoms, reverse transcriptase polymerase chain reaction (RT-PCR) positivity, effect on normal activity, need for anti-COVID-19 medication, hospitalization, and death among individuals who had completed both doses of COVID vaccination at least 2 weeks earlier.

Results  A total of 351 unique valid responses were received. Among the 340 people who had been vaccinated in India, 5% (17/340) had COVID-19 symptoms, 4.7% (16) became COVID-19 RT-PCR positive, 12 (3.5%) had sickness preventing normal daily activity, 2.65% (9) required anti-COVID-19 medication, and 1.18% (4) required hospitalization. Among family members living with the survey responders, the corresponding incidence was even lower. There was one death in this group.

Discussion  Being health care professionals, the responders would be at higher risk of daily exposure to COVID-19. Even in this high risk group, the vaccine efficacy is good. Vulture journalists should stop spreading fake news and misinformation that makes people hesitate taking the vaccine or be afflicted analysis paralysis. Every person who chooses to remain unvaccinated increases the risk for our entire community. We also need to follow universal precautions (wearing mask, physical distancing, handwashing) diligently without letting down our guard.

The usefulness of CanAssist breast in the assessment of recurrence risk in patients of ethnic Indian origin

Accurate recurrence risk assessment in hormone receptor positive, HER2/neu negative breast cancer is critical to plan precise therapy. CanAssist Breast (CAB) assesses recurrence risk based on tumor biology using artificial intelligence-based approach. We report CAB risk assessment correlating with disease outcomes in multiple clinically high- and low-risk subgroups. In this retrospective cohort of 925 patients [median age-54 (22–86)] CAB had hazard ratio (HR) of 3 (1.83–5.21) and 2.5 (1.45–4.29), P = 0.0009) in univariate and multivariate analysis. CAB's HR in sub-groups with the other determinants of outcome, T2 (HR: 2.79 (1.49–5.25), P = 0.0001); age [< 50 (HR: 3.14 (1.39–7), P = 0.0008)]. Besides application in node-negative patients, CAB's HR was 2.45 (1.34–4.47), P = 0.0023) in node-positive patients. In clinically low-risk patients (N0 tumors up to 5 cms) (HR: 2.48 (0.79–7.8), P = 0.03) and with luminal-A characteristics (HR: 4.54 (1–19.75), P = 0.004), CAB identified >16% as high-risk with recurrence rates of up to 12%. In clinically high-risk patients (T2N1 tumors (HR: 2.65 (1.31–5.36), P = 0.003; low-risk DMFS: 92.66 ± 1.88) and in women with luminal-B characteristics (HR: 3.24; (1.69–6.22), P < 0.0001; low-risk DMFS: 93.34 ± 1.34)), CAB identified >64% as low-risk. Thus, CAB prognostication was significant in women with clinically low- and high-risk disease. The data imply the use of CAB for providing helpful information to stratify tumors based on biology incorporated with clinical features for Indian patients, which can be extrapolated to regions with similarly characterized patients, South-East Asia.

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Prospective analysis of CAB prognostication in a retrospective cohort of ethnic Indian origin.

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CAB based prognostication was significant in women aged above and below 50 years.

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In clinically high-risk and women with luminal B features greater numbers were low-risk.

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In clinically low-risk and women with luminal A features greater numbers were high-risk.

Combination of immunotherapy and tyrosine kinase inhibitor in first-line metastatic renal cell carcinoma: A real-world Indian experience

e16576

Background: Immuno-oncology (IO) agents in combination with oral tyrosine kinase inhibitors (TKIs) has become a standard first line therapy in metastatic renal cell carcinoma (mRCC) patients. Various combinations such as pembrolizumab + axitinib, avelumab + axitinib, nivolumab + cabozantinib and pembrolizumab + lenvatinib have all shown better results than sunitinib. There is very limited data about this from India. Methods: This is a single center, retrospective study of mRCC patients, who received first line treatment was nivolumab or pembrolizumab with axitinib or lenvatinib. The endpoints were objective response rate (ORR), progression free survival (PFS), overall survival (OS) and adverse events (AE). Results: Between Jan 2019 to Jan 2021, 22 patients were treated with IO + TKI combination. 12 patients received axitinib, and 10 lenvatinib. Age range was 35 to 78 years with 18 males and 4 females. IMDC risk stratification showed 3 favorable (13.6%), 13 intermediate (59%) and 6 poor risk (27.2%) patients. 2 patients (9%) achieved complete response(CR), 13 (59%) partial response (PR), 4 (18.2%) had stable disease and 3 (13.6%) progressed. The ORR was 68%. Median PFS was 22 months (1 month- 24 months). OS at 1 year was 92%, and median OS was not reached. Grade 3/4 immune related adverse events (AEs) were seen in 3 (14.2%) patients (1 colitis,1 pneumonitis,1 encephalitis), for whom the IO was discontinued. TKI related grade 3/4 AEs were seen in 8 patients (38%), and were managed with dose reductions. Conclusions: Combination IO + TKI is a very effective first line therapy in mRCC. An ORR of 68%, median PFS of 22 months and 1 year OS of 92% is the best we have seen in our patients. The efficacy of this combination is seen in all IMDC subgroups. The combination is well tolerated, and the TKI AEs are comfortably managed with dose reduction. IO combinations should be preferred over single agent TKIs (sunitinib or pazopanib) as first line therapy.

CanAssist Breast Impacting Clinical Treatment Decisions in Early-Stage HR+ Breast Cancer Patients: Indian Scenario

CanAssist Breast (CAB) has thus far been validated on a retrospective cohort of 1123 patients who are mostly Indians. Distant metastasis-free survival (DMFS) of more than 95% was observed with significant separation (P < 0.0001) between low-risk and high-risk groups. In this study, we demonstrate the usefulness of CAB in guiding physicians to assess risk of cancer recurrence and to make informed treatment decisions for patients. Of more than 500 patients who have undergone CAB test, detailed analysis of 455 patients who were treated based on CAB-based risk predictions by more than 140 doctors across India is presented here. Majority of patients tested had node negative, T2, and grade 2 disease. Age and luminal subtypes did not affect the performance of CAB. On comparison with Adjuvant! Online (AOL), CAB categorized twice the number of patients into low risk indicating potential of overtreatment by AOL-based risk categorization. We assessed the impact of CAB testing on treatment decisions for 254 patients and observed that 92% low-risk patients were not given chemotherapy. Overall, we observed that 88% patients were either given or not given chemotherapy based on whether they were stratified as high risk or low risk for distant recurrence respectively. Based on these results, we conclude that CAB has been accepted by physicians to make treatment planning and provides a cost-effective alternative to other similar multigene prognostic tests currently available.

Adaptations and Safety Modifications to Perform Safe Minimal Access Surgery (MIS: Laparoscopy and Robotic) During the COVID-19 Pandemic: Practice Modifications Expert Panel Consensus Guidelines from Academia of Minimal Access Surgical Oncology (AMASO)

The pandemic of COVID-19 across the globe triggered national lockdowns hampering normal working for all the essential services including healthcare. In order to reduce transmission and safety of patients and healthcare workers, the elective surgeries have been differed. The visits to the hospitals for follow-ups and consultations received temporary halt. However, we cannot halt the treatment for cancer patients who may or may not be COVID-19 positives. These are emergencies and should be treated ASAP. Conducting emergency surgeries during pandemic like COVID-19 is challenge for surgeons and the entire hospital infrastructure. The available information about COVID-19 and its propensity of contamination through droplets and aerosol need some modifications for conducting surgeries successfully without contaminating the hospital buildings, protecting healthcare teams and the patient. With these objectives, some modifications in the operating theater including surgical techniques for minimal access, laparoscopy, and robotic surgery are proposed in this review article. This review article also discusses the safety measures to be followed for the suspected or confirmed COVID-19 patient and the guidelines and recommendations for healthcare teams while treating these patients. Although there is little evidence of viral transmission through laparoscopic or open approaches, modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device used to reduce the risk of exposure to aerosolized particles to healthcare team are proposed in this review article.

Current practice and perceptions of safety protocols for the use of intraperitoneal chemotherapy in the operating room: results of the IP-OR international survey

OBJECTIVES

To assess the risk perception and the uptake of measures preventing environment-related risks in the operating room (OR) during hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC).

METHODS

A multicentric, international survey among OR teams in high-volume HIPEC and PIPAC centers: Surgeons (Surg), Scrub nurses (ScrubN), Anesthesiologists (Anest), Anesthesiology nurses (AnesthN), and OR Cleaning staff (CleanS). Scores extended from 0-10 (maximum).

RESULTS

Ten centers in six countries participated in the study (response rate 100%). Two hundred and eleven responses from 68 Surg (32%), 49 ScrubN (23%), 45 Anest (21%), 31 AnesthN (15%), and 18 CleanS (9%) were gathered. Individual uptake of protection measures was 51.4%, similar among professions and between HIPEC and PIPAC. Perceived levels of protection were 7.57 vs. 7.17 for PIPAC and HIPEC, respectively (p<0.05), with Anesth scoring the lowest (6.81). Perceived contamination risk was 4.19 for HIPEC vs. 3.5 for PIPAC (p<0.01). Information level was lower for CleanS and Anesth for HIPEC and PIPAC procedures compared to all other responders (6.48 vs. 4.86, and 6.48 vs. 5.67, p<0.01). Willingness to obtain more information was 86%, the highest among CleanS (94%).

CONCLUSIONS

Experience with the current practice of safety protocols was similar during HIPEC and PIPAC. The individual uptake of protection measures was rather low. The safety perception was better for PIPAC, but the perceived level of protection remained relatively low. The willingness to obtain more information was high. Intensified, standardized training of all OR team members involved in HIPEC and PIPAC is meaningful.

Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients

Background:

Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery.

Materials and Methods:

This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section.

Results:

The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives.

Conclusions:

SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.

Adaptations and Safety Modifications to Perform Safe Minimal Access Surgery (Minimally Invasive Surgery: Laparoscopy and Robotic) during the COVID-19 Pandemic

It is inevitable that some patients with suspected or confirmed COVID-19 may require urgent surgical procedures. The objective of this review was to discuss the modifications required in the operating room during COVID-19 times for minimal access, laparoscopy, and robotic surgery, especially with regard to minimally invasive surgical instruments, buffalo filter, trocars with smoke evacuator, and special personal protection equipment. We have discussed the safety measures to be followed for the suspected or confirmed COVID-19 patient. In addition to surgical patients, health care workers should also protect themselves by following the guidelines and recommendations while treating these patients. Although there is little evidence of viral transmission through laparoscopic or open approaches, we recommend modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device use to reduce the risk of exposure to aerosolized particles to the health care team. Therefore, hospitals must follow specific protocols and arrange suitable training of the health care workers. Following well-established plans to accomplish un-deferrable surgeries in COVID-19-positive patients is strongly recommended.

Indian Expert Opinion on Cancer Care during COVID-19 Pandemic

Coronavirus pandemic has increased human disease burden, as well as economic distress globally. Being in an immunocompromised state, patients with cancer comprise an important at-risk population for novel coronavirus disease 2019 (COVID-19) infection. It is necessary to modify individualized clinical management for every cancer patient in the context of the ongoing COVID-19 pandemic. Simultaneously, additional safety precautions for the cancer care providers are mandatory. This review will provide general recommendations in the Indian context optimizing the same.

Current Opinion on Peritoneal Carcinomatosis Treatment: a Survey of the Indian Society of Peritoneal Surface Malignancies (ISPSM)

Purpose

Patients with peritoneal carcinomatosis (PC) are increasingly treated with multidisciplinary combined approaches. The study aim was to assess current practice and perceptions of treatment modalities of PC.

Methods

Indian Society of Peritoneal Surface Malignancies (ISPSM) members were invited to complete an online survey. Current practice and perceptions of treatment modalities were assessed through 19 closed questions. Scores were assessed using a Likert scale (0: not important, 5: very important). Treatment modality satisfaction was assessed using a semantic scale (frustrated: 0, perfectly happy: 10). Participants were sent 3 reminders at 4-week intervals.

Results

Fifty-seven out of 182 members completed the survey (31%). Forty percent of participants had an experience of at least 10 years, and 75% stated treating less than 20 PC patients per year. Main treatment goals for patients with PC were cure (5/5) and symptom relief (4/5). Participant’s satisfaction with treatment modalities for ovarian, colorectal, and gastric PC were 6/10, 5/10, and 2/10, respectively. Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian (57%) and colorectal (44%) origins were considered to be useful. Clinical usefulness of chemotherapy for gastric PC was rated to be low (17%).

Conclusions

Current treatment modalities fall short to satisfy the needs (cure, symptom relief) of patients with PC. Alternative systemic and intraperitoneal treatment modalities should be assessed.

Electronic supplementary material

The online version of this article (10.1007/s12029-020-00538-1) contains supplementary material, which is available to authorized users.

Individualized Chemotherapy Benefit Prediction by EndoPredict in Patients With Early Breast Cancer in an Indian Cohort

PURPOSE

There are new advancements in the modulation of the treatment of patients with early-stage breast cancer, including the use of several molecular profiling tests to identify or select those patients who require additional adjuvant chemotherapy together with hormonal therapy on the basis of a recurrence score. One such tool is EndoPredict (Myriad Genetics; Salt Lake City, UT), which provides support in clinical decision making. The objective of this analysis was to study the landscape of absolute chemotherapy benefit and the likelihood of recurrence within 5 to 15 years in Indian patients with breast cancer who are undergoing EndoPredict testing.

PATIENTS AND METHODS

This study included 308 patients with hormone-positive, human epidermal growth factor receptor 2–negative early breast cancer. Their postsurgical blocks were analyzed using the EndoPredict test. The MEDCALC statistical tool (Panum Education; Seoul, Republic of Korea) was used to estimate the correlation coefficient and to conduct multiple regression analysis.

RESULTS

On the basis of the EndoPredict EPclin Risk Score, 52.12% of patients were classified as being in the low-risk category and could safely forgo adjuvant chemotherapy. For every unit increase in the EPclin Risk Score, the percentage increase in absolute chemotherapy benefit was 6.82%. Similarly, the correlation between the likelihood of recurrence within 5 to 15 years and the EPclin Risk Score suggested that there is a 10.34% increase in recurrence for each unit of EPclin Risk Score.

CONCLUSION

The EPclin Risk Score has good prognostic and predictive power; it also provides the range of chemotherapy benefit for Indian patients.

Prospective Study Comparing Clinical vs Indocyanine Green Fluorescence-Based Assessment of Line of Transection in Robotic Rectal Cancer Surgery-Indian Study

Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.

Evaluation of delay in time to adjuvant chemotherapy after HIPEC and its impact on oncological outcome in advanced epithelial ovarian cancer

Obejectives

Optimal cytoreductive surgery (CRS), followed by adjuvant chemotherapy, is a major predictor of oncological outcome in patients with advanced epithelial ovarian carcinoma (EOC). It is not clear if a delayed start of adjuvant chemotherapy negatively impacts on the oncological outcome.

Methods

Prospective registry study on 75 patients treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). Adjuvant chemotherapy was started within 42 days in 41 patients (55%), later on in 34 patients (45%). Multivariate analyses of preoperative factors were done on survival outcome. Outcomes were recurrence-free survival (RFS) and overall survival (OS).

Results

There was no difference in RFS after early introduction (median 35 months) vs. late introduction of chemotherapy (median 32 months), p = 0.17. Median OS in patients with late introduction of chemotherapy was 46 months and was not yet reached in early introduction group.

Conclusions

In this exploratory study in a small group of women with advanced EOC, starting adjuvant chemotherapy more than 6 weeks after CRS and HIPEC did not deteriorate significantly RFS or OS. Well-designed clinical studies are still needed to evaluate the interplay of HIPEC and the point of time of postoperative adjuvant chemotherapy in this indication.

A prospective study of real-time identification of line of transection in robotic colorectal cancer surgery by ICG

Colorectal cancer is the second most common cancer in women and the third most common cancer in men in the world. Surgical resection is the gold standard treatment and minimally invasive surgery remains the standard of care. Anastomotic leakage is one of the most feared postoperative complications in colorectal surgery. Although several factors have been identified as possible causes of anastomotic leakage (i.e., surgical techniques, patient risk factors, suture material or devices), the complete pathogenesis is still unclear. The reported leak rate ranges from 1 to 30% and increases as the anastomosis is more distal. To date the most widely used methods to assess tissue perfusion includes the surgeon intraoperative visual judgement based on the colour; bleeding edges of resected margins; pulsation and temperature, thereby resulting in either excess or insufficient colonic resection. Earlier studies in colorectal surgery have suggested that assessment of tissue perfusion by the clinical judgment of the operating surgeon underestimated the risk of anastomotic leakage. Indocyanine green (ICG) is a intravenous dye which has shown promise in identifying the bowel vascularity real time. Earlier studies on colorectal cancer have shown that ICG based detection of bowel vascularity is technically possible and has reduced the anastomotic leak rates in 16.7% of patients. We conducted a prospective study on patients with ICG guided bowel perfusion during robotic colorectal cancer surgery. The method is technically easy, reproducible and safe. This technique has changed the intraoperative decision in 88% of patients. Larger studies are needed before this can become the standard of care.

Impact of COVID-19 Pandemic on Gynecological Oncology Care: Glimpse into Association of Gynecological Oncologists of India (AGOI) Perspective

PURPOSE

The notorious COVID 19 pandemic has caused rapid and drastic changes in cancer care worldwide in 2020. This online survey aims to assess the extent to which the pandemic has affected cancer care in gynecological oncology amongst members of the Association of Gynecological Oncologists of India (AGOI), a registered professional society founded in 1991.

METHODS

We developed and administered a cross-sectional, flash survey to members of AGOI in the first week of April 2020. Data were analyzed using Microsoft Office Excel 2016. Results were expressed as percentages of total responses excluding blank or unattended response. Overall theme-specific responses were described as a spectrum of findings, and related inferences were drawn.

RESULTS

Among approached practitioners, 90 responded to the survey, more than 80% were practicing consultants, and more than 50% from academic institutions. The results of the study showed that the ongoing pandemic had severely affected gynecological oncology practice and care amongst all respondents. There were modifications in diagnostic pathways, interventions, and follow-ups across all organ sites. There was a near-unanimous opinion on the use of general safety measures to combat the virus and to use complete PPEs in a high-risk situation. There were mixed responses to alternative educational activities, especially using electronic technology and distant learning methods. There was optimism among respondents with regards to the current situation normalizing in 3-6 months.

CONCLUSION

This study documents the pandemic affected scenario of gynecological cancer care and perceptions of Gynecological Oncologists in India. A significant effect on all aspects of cancer care was observed. Technological learning methods, both for patient care and educational activities, were being adopted by many respondents.

Can Low-cost Indo Cyanine Green Florescence Technique for Sentinel Lymph Node Biopsy Replace Dual Dye (Radio-colloid and Blue Dye) Technique in Early Breast Cancer: A Prospective Two-arm Comparative Study

BACKGROUND

The objective of this study was to assess the detection and accuracy of sentinel lymph node (SLN) biopsy (SLNB) using the low-cost indocyanine green (ICG) fluorescence method and to compare this method with the gold standard dual-dye method (radio-colloid + methylene blue dye [MB]).

MATERIALS AND METHODS

One hundred patients with node-negative early breast cancer assessed clinically and by ultrasound axilla underwent an SLNB procedure using technetium-99m radio-colloid, MB, and ICG. The detection rate of SLNs and positive SLNs and the number of SLNs were compared. The injection safety of ICG and MB was evaluated.

RESULTS

One hundred female patients with a median age of 52.3 years participated in the study. Sixty-eight percent had a body mass index < 25, 85% presented with a palpable lump, of which 59% were in the outer quadrant. SLNs were identified in all 100 cases. A total of 290 SLNs were removed (mean, 2.9; range, 1-6). The identification rate with dual dye was 94%, whereas with ICG alone, it was 96%. The SLNB sensitivity rate and false negative rate were 97.6% versus 93.2% and 3.1% versus 6.2% in the ICG and dual-dye combination, respectively. None of the patients had any local or systemic reaction with ICG; 3 patients with blue dye had tattooing and staining of skin.

CONCLUSION

ICG fluorescence imaging permits real time visualization of lymphatics and provides an additional dimension to SLN biopsy that is safe and effective. These results confirm high sensitivity for fluorescence localization with comparable performance to the gold standard. ICG can reliably replace dual dye and be employed as a sole tracer for SLNB in early breast cancer.

A prospective randomized controlled trial comparing conventional Intuitive® procedure card recommended port placement with the modified Indian (Manipal) technique

Introduction

The da Vinci^® X hybrid systems (Intuitive Surgical^®, Sunnyvale CA) provides standard sites recommendations for port placement during robotic surgery; including that for colorectal procedures. The author's encountered challenges while adhering to the provided instructions, such as clash of instruments and arms and need for additional ports, and hence to overcome these challenges attempted a few innovative technical modifications. The surgical results as well as merits of the revised Indian (Manipal) port placement with single docking technique are presented here.

Methods

Twenty patients underwent robotic rectal resection at the Department of Surgical Oncology and Robotic Surgery, Manipal Comprehensive Cancer Centre, Bengaluru, India, between December 2017 and June 2018. A randomised controlled study was conducted to compare the two techniques. Ten patients were operated using hybrid da Vinci^® 'X' system using the manufacturer's recommendations and 10 by the modified Indian (Manipal) port placement with a single docking technique.

Result and Conclusions

The Indian (Manipal) modifications of port placements are optimal for colorectal procedures such as low anterior resection as well as for ultralow anterior resections. The intraoperative parameters compared between the recommendations of the Intuitive^® (da Vinci^® systems) and attempted modifications demonstrated statistically significant advantages with the use of the revised techniques. The improvements offered by this modification include no additional requirements of ports or staplers, lesser clash amongst instruments as well as arms, better mobilisation of splenic flexure amongst others.

Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC

Background

In peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

This was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed.

Results

Of the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3–G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan–Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively.

Conclusions

Performing TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.

Toxicity profile of chemotherapy agents used in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies

INTRODUCTION

Morbidity associated with cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is due to the synergistic effect of cytoreduction, effect hyperthermia and the cytotoxic agents used for HIPEC. This study was done to analyse the postoperative morbidity in relation to the chemotherapy agent used in patients undergoing CRS-HIPEC for peritoneal surface malignancy (PSM) in Indian set up.

MATERIALS AND METHODS

Patient with PSM, underwent CRS-HIPEC as per the institutional protocol. Patients were stratified as per the chemotherapy drug used during HIPEC & perioperative outcome were documented.

RESULTS

163 patients underwent CRS-HIPEC for PSM: 67.4% were of ovarian primary. Others were colorectal, appendicular, gastric primary and rare tumors.Cisplatin was the most common drug used: as alone (57.05%) or in combination with Adriamycin (12.88%). Mitomycin-C (MMC) was used in 20% and oxaliplatin in 10%.Grade 3-5 morbidity in the whole cohort was 44.8% and grade 1-2 was 74%.Grade 1-2 electrolyte abnormality was the most common morbidity overall and grade 3-4 hematological toxicity was the most common severe morbidity. Frequency of grade 3-5 morbidity were 38.7%, 48.5%,50% and 61.9% for Cisplatin alone, MMC, oxaliplatin and Adriamycin + cisplatin respectively. None of the patients had grade 3-4 nephrotoxicity as sole complication. All major complications were highest in the group who received Adriamycin. Cisplatin was associated with higher rate of electrolyte imbalance, oxaliplatin with post-operative bleeding. Rates of other complications did not differ significantly.

CONCLUSION

Cisplatin followed by MMC were the well tolerated drugs during HIPEC and tolerance to Adriamycin combination regimen in Indian patients was poor.

cAMP regulated EPAC1 supports microvascular density, angiogenic and metastatic properties in a model of triple negative breast cancer

Breast cancer is a leading cause of cancer-related mortality in women. Triple-negative breast cancer (TNBC; HER2-, ER-/PR-) is an aggressive subtype prone to drug resistance and metastasis, which is characterized by high intratumor microvascular density (iMVD) resulting from angiogenesis. However, the mechanisms contributing to the aggressive phenotypes of TNBC remain elusive. We recently reported that down-regulation of exchange factor directly activated by cyclic AMP (cAMP), also known as EPAC1, leads to a reduction in metastatic properties including proliferation and cell migration in TNBC cell lines. Here, we report that EPAC1 supports TNBC-induced angiogenesis, tumor cell migration and invasiveness as well as pro-metastatic phenotypes in endothelial cells induced through the tumor secretome. Using an approach that integrates proteomics with bioinformatics and gene ontologies, we elucidate that EPAC1 supports a tumor-secreted network of angiogenic, cell adhesion and cell migratory pathways. Using confocal microscopy, we show that signaling molecules involved in focal adhesion, including Paxillin and MENA, are down-regulated in the absence of EPAC1, and electric cell substrate impedance sensing technique confirmed a role for EPAC1 on TNBC-induced endothelial cell permeability. Finally, to provide a translational bridge, we studied iMVD and therapy response using a primary human tumor explant assay, CANscriptTM, which suggests a link between therapy-modulated neovascularization and drug sensitivity. These data provide mechanistic insight into the role of EPAC1 in regulating the tumor microenvironment, iMVD and cancer cell-induced angiogenesis, a dynamic mechanism under drug pressure that may associate to treatment failure.

Watson for Oncology and breast cancer treatment recommendations: agreement with an expert multidisciplinary tumor board

Background

Breast cancer oncologists are challenged to personalize care with rapidly changing scientific evidence, drug approvals, and treatment guidelines. Artificial intelligence (AI) clinical decision-support systems (CDSSs) have the potential to help address this challenge. We report here the results of examining the level of agreement (concordance) between treatment recommendations made by the AI CDSS Watson for Oncology (WFO) and a multidisciplinary tumor board for breast cancer.

Patients and methods

Treatment recommendations were provided for 638 breast cancers between 2014 and 2016 at the Manipal Comprehensive Cancer Center, Bengaluru, India. WFO provided treatment recommendations for the identical cases in 2016. A blinded second review was carried out by the center's tumor board in 2016 for all cases in which there was not agreement, to account for treatments and guidelines not available before 2016. Treatment recommendations were considered concordant if the tumor board recommendations were designated 'recommended' or 'for consideration' by WFO.

Results

Treatment concordance between WFO and the multidisciplinary tumor board occurred in 93% of breast cancer cases. Subgroup analysis found that patients with stage I or IV disease were less likely to be concordant than patients with stage II or III disease. Increasing age was found to have a major impact on concordance. Concordance declined significantly (P ≤ 0.02; P < 0.001) in all age groups compared with patients <45 years of age, except for the age group 55-64 years. Receptor status was not found to affect concordance.

Conclusion

Treatment recommendations made by WFO and the tumor board were highly concordant for breast cancer cases examined. Breast cancer stage and patient age had significant influence on concordance, while receptor status alone did not. This study demonstrates that the AI clinical decision-support system WFO may be a helpful tool for breast cancer treatment decision making, especially at centers where expert breast cancer resources are limited.

Pressurized IntraPeritoneal Aerosol Chemotherapy vs. intravenous chemotherapy for unresectable peritoneal metastases secondary to platinum resistant ovarian cancer - study protocol for a randomized control trial

Background

Despite optimal surgery and appropriate first-line chemotherapy, ∼70–80 % of patients with epithelial ovarian cancer will develop disease relapse. The prognosis is poor especially for women with Platinum resistant ovarian cancer. The standard treatment for these groups of patients is non-platinum-containing chemotherapy like taxanes, anthracyclines, gemcitabine, topotecan, and trabectedin. These drugs in various combinations and sequences provide modest survival or symptomatic benefit but with significant side effects. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally-invasive drug-delivery technique specifically addressing limited tissue penetration and poor drug distribution with promising results. PIPAC is a novel method of delivering normothermic chemotherapy into the abdominal cavity as an aerosol under pressure. This concept seems to enhance the effectiveness of intra peritoneal chemotherapy by taking advantage of the physical properties of gas and pressure by generating an artificial pressure gradient and enhancing tissue uptake and distributing drugs homogeneously within the closed and expanded peritoneal cavity. Thus, due to the high local bioavailability during PIPAC, the chemotherapy dosage can be reduced which in turn largely prevents systemic side effects and organ toxicity.

Methods

The study aims to investigate the therapeutic efficacy measured as objective tumour response according to Response Evaluation Criteria in Solid Tumours (RECIST) criteria, of PIPAC in comparison with conventional Intravenous chemotherapy for women with recurrent platinum resistant ovarian cancer with peritoneal metastasis (PM). Consecutive patients diagnosed with PM secondary to platinum-resistant ovarian cancer will be randomized to PIPAC group or IV chemotherapy group. The primary objective of this study is to determine the efficacy after three cycles of PIPAC with cisplatin and doxorubicin in comparison with six cycles of systemic chemotherapy. The secondary outcome measures include morbidity and mortality, overall survival and disease specific survival. Analysis is by intention to treat.

Aim

Assess the objective tumour response of PIPAC in comparison with systemic intravenous chemotherapy for women with platinum-resistant ovarian cancer.

Study type

Prospective randomized control intervention trial.

Intervention model

IV Chemotherapy group (Control group) PIPAC group (Experimental group)

Masking

Open label.

Primary purpose

Treatment.

Sample size

Calculated sample size is 97 and rounded to 100. For each treatment group sample size of 50 will be considered.

Primary outcome criteria

Objective tumour response according to Response Evaluation Criteria in Solid Tumours (RECIST) criteria version 1.1.

Discussion

PIPAC in women with platinum resistant ovarian PM has good response owing to superior tissue penetration and better drug distribution. The procedure is safe and well tolerated owing it to its minimal invasiveness. Typical side-effects of systemic chemotherapy, such as alopecia, peripheral neurotoxicity, nausea and myelosuppression are absent. We expect reduction of ascites with symptomatic relief and CA 125 levels. PIPAC is a novel technique for selected patients with platinum resistant ovarian PM and further investigation in comparative clinical trials with conventional chemotherapy will establish its role as a good palliative treatment option.

Ethics committee approval

Obtained.

Status

Recruiting.

Trial registration number

REF/2018/08/021223 Registered on Clinical Trials Registry – India (CTRI); www.ctri.nic.in

Clinical validation of an immunohistochemistry-based CanAssist-Breast test for distant recurrence prediction in hormone receptor-positive breast cancer patients

CanAssist‐Breast (CAB) is an immunohistochemistry (IHC)‐based prognostic test for early‐stage Hormone Receptor (HR+)‐positive breast cancer patients. CAB uses a Support Vector Machine (SVM) trained algorithm which utilizes expression levels of five biomarkers (CD44, ABCC4, ABCC11, N‐Cadherin, and Pan‐Cadherin) and three clinical parameters such as tumor size, grade, and node status as inputs to generate a risk score and categorizes patients as low‐ or high‐risk for distant recurrence within 5 years of diagnosis. In this study, we present clinical validation of CAB. CAB was validated using a retrospective cohort of 857 patients. All patients were treated either with endocrine therapy or chemoendocrine therapy. Risk categorization by CAB was analyzed by calculating Distant Metastasis‐Free Survival (DMFS) and recurrence rates using Kaplan‐Meier survival curves. Multivariate analysis was performed to calculate Hazard ratios (HR) for CAB high‐risk vs low‐risk patients. The results showed that Distant Metastasis‐Free Survival (DMFS) was significantly different (P‐0.002) between low‐ (DMFS: 95%) and high‐risk (DMFS: 80%) categories in the endocrine therapy treated alone subgroup (n = 195) as well as in the total cohort (n = 857, low‐risk DMFS: 95%, high‐risk DMFS: 84%, P < 0.0001). In addition, the segregation of the risk categories was significant (P = 0.0005) in node‐positive patients, with a difference in DMFS of 12%. In multivariate analysis, CAB risk score was the most significant predictor of distant recurrence with hazard ratio of 3.2048 (P < 0.0001). CAB stratified patients into discrete risk categories with high statistical significance compared to Ki‐67 and IHC4 score‐based stratification. CAB stratified a higher percentage of the cohort (82%) as low‐risk than IHC4 score (41.6%) and could re‐stratify >74% of high Ki‐67 and IHC4 score intermediate‐risk zone patients into low‐risk category. Overall the data suggest that CAB can effectively predict risk of distant recurrence with clear dichotomous high‐ or low‐risk categorization.

Pressurized intraperitoneal aerosol chemotherapy procedure for nonresectable peritoneal carcinomatosis: First Indian study

BACKGROUND

Peritoneal carcinomatosis (PC) is a common evolution of abdominal cancers and is associated with poor prognosis. A few selected patients have option of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, but majority who are not eligible for curative approach can undergo pressurized intraperitoneal aerosol chemotherapy (PIPAC). It is an emerging field of research with major therapeutic potential. It is a safe and innovative approach, which enhances the effect of chemotherapy without major toxicity.

METHODS

Between June 2017 and December 2017, 21 PIPAC applications in seven patients with standard chemotherapy regimen every 6 weeks at 37°C and 12 mmHg for 30 min was performed. The patients' demographics, perioperative findings, adverse events, and outcomes were prospectively recorded.

RESULTS

Twenty-one PIPAC administrations were performed in 7 patients with PC from various pathologies. The median hospital stay was 1 day. All the patients had symptomatic relief with complete resolution of ascites. There was no major perioperative complications. CTCAE Grades 1 and 2 were observed in three patients, for abdominal pain and nausea. Renal and hepatic functions were not impaired. Of the seven patients, one patient had complete histological remission; three patients had partial response, one had stable disease and one patient had no response with clinical progression.

CONCLUSION

Our results show the feasibility and safety of PIPAC in Indian patients. The procedure has low morbidity with no mortality with the short learning curve. It can be easily adapted for Indian patients with diffuse PC as a palliative option apart from systemic chemotherapy.