Preoperative therapy in locally advanced esophageal cancer

Esophageal cancer is an aggressive malignancy associated with dismal treatment outcomes. Presence of two distinct histopathological types distinguishes it from other gastrointestinal tract malignancies. Surgery is the cornerstone of treatment in locally advanced esophageal cancer(T2 or greater or node positive); however, a high rate of disease recurrence(systemic and loco-regional) and poor survival justifies a continued search for optimal therapy. Various combinations of multimodality treatment(preoperative/perioperative, or postoperative; radiotherapy, chemotherapy, or chemoradiotherapy) are being explored to lower disease recurrence and improve survival. Preoperative therapy followed by surgery is presently considered the standard of care in resectable locally advanced esophageal cancer as postoperative treatment may not be feasible for all the patients due to the morbidity of esophagectomy and prolonged recovery time limiting the tolerance of patient. There are wide variations in the preoperative therapy practiced across the centres depending upon the institutional practices, availability of facilities and personal experiences. There is paucity of literature to standardize the preoperative therapy. Broadly, chemoradiotherapy is the preferred neo-adjuvant modality in western countries whereas chemotherapy alone is considered optimal in the far East. The present review highlights the significant studies to assist in opting for the best evidence based preoperative therapy(radiotherapy, chemotherapy or chemoradiotherapy) for locally advanced esophageal cancer.

Targeted therapy of gastrointestinal stromal tumours

Gastrointestinal stromal tumours(GISTs) are mesen-chymal neoplasms originating in the gastrointestinal tract, usually in the stomach or the small intestine, and rarely elsewhere in the abdomen. The malignant potential of GISTs is variable ranging from small lesions with a benign behaviour to fatal sarcomas. The majo-rity of the tumours stain positively for the CD-117(KIT) and discovered on GIST-1(DOG-1 or anoctamin 1) expression, and they are characterized by the presence of a driver kinase-activating mutation in either KIT or platelet-derived growth factor receptor α. Although surgery is the primary modality of treatment, almost half of the patients have disease recurrence following surgery, which highlights the need for an effective adjuvant therapy. Traditionally, GISTs are considered chemotherapy and radiotherapy resistant. With the advent of targeted therapy(tyrosine kinase inhibitors), there has been a paradigm shift in the management of GISTs in the last decade. We present a comprehensive review of targeted therapy in the management of GISTs.

Giant exophytic renal angiomyolipoma masquerading as a retroperitoneal liposarcoma: A case report and review of literature

A 42-years-old lady, presented with a large retroperitoneal mass which was preoperatively diagnosed as a retroperitoneal liposarcoma following an image guided core biopsy. She underwent a margin-negative resection of the retroperitoneal mass(multi visceral resection-enbloc excision of the retroperitoneal mass with a left nephrectomy and a segmental descending colectomy). The final histopathological examination of the resected specimen confirmed an exophytic renal angiomyolipoma(AML) which was extending into the retroperitoneum. AML is a rare benign tumor arising most commonly from the kidney. It can sometimes present as a diagnostic challenge as it mimics a retroperitoneal liposarcoma or a fat-containing renal cell carcinomas closely. We present this case to share our experience of managing a case of giant exophytic AML which resembled retroperitoneal liposarcoma closely and resulted into an aggressive surgery.

Spontaneous rupture of the renal pelvis presenting as an urinoma in locally advanced rectal cancer

A 29-year-old gentleman underwent a transverse colostomy for intestinal obstruction caused by advanced rectal carcinoma. On the 5th postoperative day, the patient developed a painful swelling on the right side of the abdomen. The contrast enhanced computed tomography of the abdomen revealed a right sided hydronephrosis, a large rent in the renal pelvis, and a large retroperitoneal fluid collection on the right side. Percutaneous nephrostomy and pigtail catheter drainage of the urinoma led to resolution of abdominal swelling. Development of a urinoma as a consequence of rectal carcinoma is highly unusual. Prompt imaging for confirmation of diagnosis, decompression of the renal pelvicalyceal system, and drainage of the urinoma limits morbidity.

Role of positron emission tomography-computed tomography in non-small cell lung cancer

Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small cell carcinoma and small cell carcinoma are the main histological subtypes and constitutes around 85% and 15% of all lung cancer respectively. Multimodality treatment plays a key role in the successful management of lung cancer depending upon the histological subtype, stage of disease, and performance status. Imaging modalities play an important role in the diagnosis and accurate staging of the disease, in assessing the response to neoadjuvant therapy, and in the follow-up of the patients. Last decade has witnessed voluminous upsurge in the use of positron emission tomography-computed tomography(PET-CT); role of PET-CT has widened exponentially in the management of lung cancer. The present article reviews the role of 18-fluoro-deoxyglucose PET-CT in the management of non small cell lung cancer with emphasis on staging of the disease and the assessment of response to neoadjuvant therapy based on available literature.

Subcutaneous and breast metastasis from asymptomatic gallbladder carcinoma

BACKGROUND:Though gallbladder carcinoma is asso- ciated with early lymphatic and hematogenous spread, the only common extra-abdominal site of metastasis is lung.Gallbladder carcinoma metastasizing to breast and subcutaneous tissue is not known. METHOD:This report describes an interesting and unusual case of asymptomatic gallbladder carcinoma presenting with subcutaneous and breast metastasis. RESULTS:A 42-year-old woman presented with multiple subcutaneous nodules over the abdominal wall,anterior chest wall,back and in bilateral breasts.Fine needle aspiration cytology(FNAC)of these nodules revealed metastatic adenocarcinoma.The patient was investigated for a primary neoplasm.An ultrasound of the abdomen followed by a contrast-enhanced CT scan showed a growth in gallbladder,infiltrating the liver with multiple hepatic metastases.CT-guided FNAC from the growth in the gallbladder revealed adenocarcinoma.She was diagnosed as a case of metastatic adenocarcinoma of the gallbladder and palliative combination chemotherapy with gemcitabine and carboplatin was given.But she developed jaundice and deteriorated dramatically in a short span of time.No specific therapy could be started and she was given supportive treatment.She died within three weeks of diagnosis due to hepatic encephalopathy. CONCLUSIONS:This report highlights an unusual metastasis of gallbladder carcinoma to the breast and subcutaneous tissue presenting as multiple lesions,which has never been reported in the English literature.These were unknown sites of metastasis for carcinoma of the gallbladder.Moreover,bilateral multiple metastatic lesions to breast are also very rare.

Mixed Saddle Point and Its Equivalence with an Efficient Solution under Generalized (V, <i>p</i>)-Invexity

The purpose of this paper is to define the concept of mixed saddle point for a vector-valued Lagrangian of the non-smooth multiobjective vector-valued constrained optimization problem and establish the equivalence of the mixed saddle point and an efficient solution under generalized (V, p)-invexity assumptions.

Lymphadenectomy in gastric cancer: Contentious issues

The stomach is the sixth most common cause of cancer worldwide. Surgery is an important component of the multi-modality treatment of the gastric cancer. The extent of lymphadenectomy has been a controversial issue in the surgical management of gastric cancer. The East-Asian surgeons believe that quality-controlled extended lymphadenectomy resulting in better locoregional control leads to survival benefit in the gastric cancer; contrary to that, many western surgeons believe that extended lymphadenectomy adds to only postoperative morbidity and mortality without significantly enhancing the overall survival. We present a comprehensive review of the lymphadenectomy in the gastric cancer based on the previously published randomized controlled trials.

Regional lymphadenectomy in advanced ovarian cancer: The enigma continues

The role of regional lymphadenectomy has always been a matter of discussion in the surgical management of solid tumors–Pelvic and para-aortic lymphadenectomy in ovarian cancer is one such issue.A recently published randomized trial suggested that regional lymphadenectomy in patients with advanced ovarian cancer is unlikely to offer a survival advantage.However,para-aortic and pelvic lymphadenectomy is warranted in the presence of macroscopically suspicious nodes to achieve complete cytoreduction.A longterm follow-up of the trial will demonstrate whether a prophylactic regional lymphadenectomy is associated with survival benefit in a subgroup of patients with advanced ovarian cancer who have grossly normal regional lymphnodes as evident in a widely open retroperitoneum.