Tertiary Cancer Center In India Research Articles

Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center

Background: Limb salvage surgery (LSS) is the current surgical standard for malignant bone tumors. The advancements in imaging, surgical techniques, chemotherapy, and biomedical engineering have made LSS oncologically safe and with improved functional outcome. In this retrospective study, we report our experience with LSS and perioperative chemotherapy for osteosarcoma in a tertiary cancer center in India. Materials and Methods: A total of 41 LSS were performed from January 2009 to January 2015. Perioperative chemotherapy was administered to all patients after histopathological confirmation of osteosarcoma. The functional outcome of the patients was evaluated using the musculoskeletal tumor society (MSTS) scoring system at regular intervals. Statistical analysis involved the use of descriptive and inferential statistics for data analysis. Kaplan–Meier method was used for calculating the recurrence free and overall survival (OS) and log-rank test for comparing survival functions. Spearman and Karl Pearson's methods were used for correlation analysis. Results: The mean age was 19.3 years (range, 8–49 years). Twenty-five (61%) patients were males. Thirty-six (88%) patients had conventional high-grade osteosarcoma. Five-year relapse-free survival and OS were 56.1% ± 7.8% (95% confidence interval [CI], 53.7–58.5) and 58.5% ± 7.7% (95% CI, 56.1–60.9), respectively. The mean MSTS scores at 1 year for tumors of the upper tibia and distal femur were 64 and 75.9, respectively. Patients with high rate of chemotherapy-induced tumor necrosis (>99%) had significantly better median OS (85.70 ± 8.22 months) compared to those with less ( Conclusion: The oncological and functional outcomes in osteosarcoma patients in the present study are comparable to those from the world literature. Chemotherapy-induced tumor necrosis is a favorable prognostic factor for patients treated for osteosarcoma with curative intent.

Prevalence and predictors of overweight and obesity among survivors of childhood acute lymphoblastic leukemia: Experience from a tertiary cancer center in india

Prevalence and predictors of overweight and obesity among survivors of childhood acute lymphoblastic leukemia: Experience from a tertiary cancer center in india

High-dose interstitial brachytherapy for accelerated partial-breast irradiation in clinical practice: Preliminary results from a tertiary cancer center in India

Introduction: Over the past several years, there has been growing interest in the use of accelerated partial-breast irradiation (APBI) as an alternative to whole-breast radiation in properly selected patients. The use of multicatheter interstitial brachytherapy (MIB) for APBI is increasing due to better availability of expertise and experience than other forms of APBI. The use of APBI outside the framework of a clinical trial has markedly increased. We report the efficacy and safety of APBI through high-dose-rate (HDR) MIB for early-stage breast cancer. Materials and Methods: Between 2008 and 2017, 20 prospectively selected patients with early-stage breast cancer received APBI using MIB following breast-conserving surgery. The mean age was 62.85 years (range: 41–80). Mean size of the tumor was 2.04 cm. The dose of 34 Gy in 10 fractions given twice daily (3.4 Gy) over 5 days was delivered to the tumor bed plus a 2-cm margin. The mean follow-up was 57.75 months (range: 12–100). Ten (50%) patients received adjuvant chemotherapy. Thirteen (65%) patients received hormonal therapy. Results: A total of 18 (90%) patients reported having excellent-to-good cosmesis, while 2 (10%) had fair-to-poor cosmesis. All patients (100%) were clinically controlled at follow-up, i.e., no locoregional recurrence. Only three (15%) had distant metastasis on follow-up. Conclusion: APBI using HDR-MIB was associated with excellent local control, acceptable toxicity, and cosmesis for early-stage breast cancer patients.

Higher incidence of syndrome of inappropriate antidiuretic hormone secretion during induction chemotherapy of acute lymphoblastic leukemia in indian children.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a well-known adverse effect of vincristine (VCR). Literature suggests that Asians are predisposed to develop SIADH following VCR administration. However, data regarding the occurrence of SIADH in children with malignancy are limited. This study aims to analyze the incidence, clinical picture, risk factors, management, and outcome of SIADH during induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL). A prospective study was conducted among the 166 newly diagnosed pediatric ALL patients who were treated at a tertiary cancer center in India between January 2015 and December 2015. Patients who developed hyponatremia during induction chemotherapy were further investigated for SIADH. The incidence of SIADH was 10.8% (n = 18) with a mean sodium level of 125 mEq/L (114-129 mEq/L). In the preceding 2 weeks, 72% of episodes were associated with the administration of two (n = 6) or three (n = 7) doses of VCR. One child presented with seizures. All the patients were managed with fluid restriction and only two patients required sodium correction with 3% saline. Girls older than 10 years of age showed a marginally significant correlation to develop SIADH (P-value = 0.059). We report a higher incidence of SIADH (10.8%) in Indian children, compared to that described in the literature, during induction chemotherapy for ALL. Regular monitoring of sodium levels during this period of chemotherapy is hence essential for the timely diagnosis and appropriate management of SIADH, which in turn will avert complications, including neurological symptoms secondary to SIADH.

Patterns of Infection and Mortality Associated with Intensive AML Induction Therapy: 10 Year Experience from a Tertiary Cancer Centre in India

Introduction: The treatment of acute myeloid leukaemia (AML) with intensive induction regimens remains a challenge in low and middle incomes countries. Early induction related deaths particularly due to infectious complications are a major problem. This is in stark contrast to high-income countries where induction mortality has declined significantly over the last 2 decades with improved antibiotic use and supportive care. In this study we assess induction mortality (all cause and infection related) in AML patients who received intensive induction therapy in a tertiary cancer centre in India over a 10-year period (2008-2017).Methods: We included patients with newly diagnosed AML treated at Cancer Institute, Chennai in South India who received intensive induction therapy. Intensive therapy was defined as use of any anthracycline with cytarabine (3+7/ADE/others). We assessed baseline demographics including age, gender, cytogenetic risk status, and type of induction regimen used. We also assessed key clinical outcomes including patterns of antimicrobial prophylaxis and treatment, infectious complications, cause of death, ICU stay, and length of hospital stay. Induction mortality was defined as deaths occurring within 45 days of initiating treatment for AML or start of 2nd induction.Results: Between January 2008 and December 2017, 510 patients with AML were evaluated at Cancer Institute, Chennai and accepted for treatment. Excluding 51 patients with APML and 55 patients who were unfit for intensive induction, 404 patients received treatment with an intensive induction regimen. Median age was 23 years (Range: 1-74 years) and 219 (54.2%) were male patients. 165(40.8%) patients were less than 18 years of age. Among those who had cytogenetic and/ molecular data for risk stratification [N=341 (84.7%)], 101 (29.6%) were low risk, 166 (48.7%) intermediate risk and 74 (21.7%) high risk. Therapy details: 318 (78.7%) patients received daunorubicin and cytarabine (‘3+7‘), 52 (12.9%) received ADE, and 38 (8.4%) received other combinations ofdaunorubicin and cytarabine.87(21.5%) of the cases had infection at the time of presentation. 389(96.8%) had an episode of febrile neutropenia with 184(45.5%) requiring management in Intensive Care Unit (ICU). Focus of infection could be identified in 294(72.7%) of the patients with 207(51.2%) having a positive culture.The overall incidence of induction mortality over the entire study period was 15.6%(n=63)and 14.8% for the most recent year included (2017). The majority of the deaths (n=53; 84.1%) were due to infectious complications (fig1). Median time to death from start of induction was 19 days. The incidence of fungal pneumonia significantly reduced since 2012 when thethe antifungal prophylaxis was switched from fluconazole to voriconazole (p=0.03). Starting in 2012, an increase in the incidence of multi-drug resistance (MDR) gram negative septicaemia and mortality (MDR: carbapenem resistant enterobacteriaceasensitive only to colistin and tigecycline) was noted. This led to proactive use of colistin in patients with febrile neutropenia and septic shock, a GI focus or baseline stool colonisation by MDR gram negative organisms.Despite this, during the last 4 years(2014-2017), there has been a significant rise in the incidence of sepsis and death due to MDR gram negative organisms (fig2). The proportion of deaths attributable to MDR sepsis is 23.8%. The early use of colistin, tigecycline and carbapenems did not significantly decrease the mortality.Conclusions: The induction mortality remains high at 15.6% and is in contrast to the declining induction mortality in high-income countries. While the morbidity and mortality due to specific infections (specifically fungal pneumonia) have changed over time, there is no signfiicant decline in infectious or all cause induction mortality over the 10 years. In the last four years, MDR gram negative sepsis has been a major cause of morbidity and mortality. The early and increased use of broad spectrum antibiotics like tigecycline, colistin and carbapenems has not led to a decrease in MDR gram negative sepsis. Overall, despite improvements in supportive care and early use of broad spectrum antimicrobial agents, infection related morbidity and mortality remains a substantial challenge in treating acute myeloid leukaemia in low- and middle-income countries. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

46P - Repeat biopsy a must in recurrent breast cancer: A study from tertiary cancer centre in India

46P - Repeat biopsy a must in recurrent breast cancer: A study from tertiary cancer centre in India

Feasibility of Wait and Watch Approach after Neoadjuvant Chemoradiotherapy in Rectal Cancer in Low- and Middle-Income Countries: Initial Experience in Tertiary Cancer Centre in India

Wait and watch (W & W) approach after response to neoadjuvant chemoradiotherapy (NACRT) in locally advanced rectal cancer (LARC) is standard of care in medically inoperable patients. Otherwise, its use is recommended in a controlled research setting. In low- and middle-income countries (LMICs) there is presumed noncompliance with strict follow-up protocol of W & W approach due to geographical vastness, limited resources, and poor socioeconomic status. The objective of this study is to assess the feasibility, acceptance, and subsequent compliance to W & W approach after the clinical complete response (cCR) and near clinical complete response (ncCR) to NACRT in LARC. Patients diagnosed with LARC from September 2013 to January 2018 who had cCR and ncCR to NACRT (Radiotherapy dose 45-55 Gy) were offered either surgery as standard of care or W & W approach with strict follow up protocol consisting of regular digital rectal examination (DRE), magnetic resonance imaging (MRI) and sigmoidoscopy with informed consent. The cCR was defined as no palpable abnormality on DRE, white scar with telangiectasia on sigmoidoscopy and absence of residual tumor on T2W-MRI. The ncCR was defined as superficial soft irregularity or small flat ulcer at DRE, small residual flat ulcer or irregular wall thickening on the sigmoidoscopy and significant downstaging with/without residual fibrosis, but with a heterogeneous or irregular aspect on MRI. The first evaluation was done at 6-8 weeks after completion of NACRT and subsequently at 12 weeks. In this retrospective observational study, data was extracted from prospectively maintained rectal cancer database at our institution. All 28 patients (stage II = 14%, stage III = 86%) with cCR and ncCR preferentially opted for W & W approach over surgery. All 28 patients complied to a strict follow-up protocol of W & W approach. Median follow up was 47 weeks (Range 8 – 397 weeks). Eleven patients had cCR and 17 patients had ncCR after NACRT. All the 11 patients with cCR had no local regrowth, no regional or distant metastasis, or death. Five patients out of the total 17 patients in ncCR group developed cCR up to 1 year, 9 patients maintained ncCR, 1 patient developed regional and distant metastasis and died. Two patients underwent surgery due to the persistent ulcer at 21 weeks and 27 weeks after NACRT. Abdominoperineal resection was done for one patient and other underwent intersphincteric resection (ISR), both pT2 pN0 with TRG 2 and 3. Two patients had local regrowth, and one of them at 48 weeks underwent ISR. Other one had regrowth at 29 weeks and planned for surgery. In the entire cohort, organ preservation rate is 89.3%, local regrowth free rate (LRFR) is 89.3%, 2 Year PFS 82%, and 2 year OS is 91.7% using the Kaplan-Meier method. The W & W approach after cCR and ncCR to NACRT in LARC is acceptable with full compliance, feasible in LMICs in well-selected patients as a part of study group in a controlled research setting and early outcomes of this approach are similar to published literature.

403P - Pineal parenchymal tumors: Patterns of care from a tertiary cancer centre in India

Background: The aim of this study is to report clinical features and treatment outcome of pineal parenchymal tumors (PPTs). Methods: Between 2006-2017, medical records of 34 patients of PPTs were analyzed to study patterns of care of patients who received adjuvant radiotherapy (RT) with or without chemotherapy (CT) following surgery. Overall survival (OS) and progression-free survival (PFS) were analyzed by Kaplan- Meier method. Results: According to WHO classification, the study comprises of 19 pineoblastomas (PB), 11 pineal parenchymal tumors of intermediate differentiation (PPTID) and 4 pineocytomas (PC). Median age at presentation was 10, 26 and 30 years, respectively. Headache was commonest symptom (77%) followed by visual disturbance. 59% underwent surgical resection and 41% had biopsy only. Median MIB labelling index of PPTIDs was 6%, whereas it was 35% in PB and 2% in PC. Spinal drop metastasis was present in 8 patients with PB and 3 patients with PPTIDs. All PBs and PPTIDs with spinal drop metastasis (2) received cranio-spinal irradiation (CSI) and adjuvant CT. The rest of the PPTIDs and PC received focal RT to the brain. The commonest regimen was a combination of carboplatin and etoposide (CE), used in 6 (32 %) PB. CE with vincristine and IT-MTX was given in patients who developed drop metastasis subsequently. At a median follow-up of 16 months, 9 (47%) patients of PB and 3 (27%) of PPTID developed recurrence in cranio-spinal axis. 5 year progression-free survival was 41%, 62% and 75%, respectively. Median overall survival (OS) was 27, 50, 18 months, and 5 year OS was 38%, 47% and 75%, respectively. Conclusions: PPTs reflect a broad spectrum of malignant potential and prognosis. PB is an aggressive tumor and requires adjuvant CSI and CT following surgery. PPTIDs are relatively rare and require meticulous pretreatment evaluation of neuraxis and knowledge of pathological factors for management. Multi-institutional cooperation in the form of prospective studies is recommended in view of rarity of tumor. Legal entity responsible for the study: AIIMS, New Delhi. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Outcomes of Patients with Splenic Marginal Zone Lymphoma Treated with Rituximab or Splenectomy: Report from Tertiary Cancer Center in India

Outcomes of Patients with Splenic Marginal Zone Lymphoma Treated with Rituximab or Splenectomy: Report from Tertiary Cancer Center in India

Risk-based management strategy and outcomes of tumor lysis syndrome in children with leukemia/lymphoma: Analysis from a resource-limited setting.

Data from low- and middle-income countries on tumor lysis syndrome (TLS) in the pediatric population are limited. This study aims to analyze the clinical and biochemical characteristics and treatment outcomes of TLS in children with leukemia/lymphomas in a resource-limited setting. Children with intermediate risk (IRD) and high risk (HRD) for developing TLS were retrospectively studied at a tertiary cancer center in India. Over a three-year period, 224 children with acute leukemia/lymphoma having IRD (21.8%, n=49) and HRD (78.1%, n=175) were identified. TLS developed in 53.6% (n=120) cases, of which 75% (n=90) had laboratory TLS alone. Thirteen children had clinical TLS (C-TLS) at presentation while 17 patients progressed to develop C-TLS. TLS developed in 51% (n=25) and 54.5% (n=95) of children with IRD and HRD, respectively. Rasburicase was used in 8.5% (n=19) cases and five children required hemodialysis. Two children (0.8%) expired during the course of TLS management. Multivariate analysis identified the presence of hyperuricemia as the single significant risk factor for developing TLS. When children in whom a 25% change in biochemical values from the baseline that falls within the normal range were excluded, 21.4% (48/224) cases were identified to have clinically relevant TLS (8% in IRD and 25% in HRD). With hydration, supportive care and judicious use of rasburicase, it is feasible to manage TLS efficiently in resource-limited settings. A modification of the TLS definition criteria would help to identify clinically relevant TLS.

Parvoviral disease in childhood cancer: Clinical outcomes and impact on therapy at a tertiary cancer center in India.

Parvovirus-B19 disease in immunocompromised children can cause myelosuppression and therapeutic delays. We studied the clinical profiles of children having symptoms suggestive of parvoviral disease at our institution, a large tertiary cancer center. Children below age 15 years undergoing treatment for malignancies with clinical features suggestive of parvoviral infection, and/or unexplained drop in hemoglobin, and/or prolonged cytopenia were screened for parvovirus infection using DNA-PCR for parvovirus-B19 (PB19) in the peripheral blood. Patients testing positive from September 2014 till February 2017 were studied. Of the 59 patients (36 patients with hematolymphoid malignancies, 23 with solid tumors) screened for suspected parvoviral infections, 27 tested positive. Median age was 9.6 years (2.25-15 years), 18 (66%) had hematolymphoid malignancies, while 7 (33%) had solid tumors. Six patients (26%) were on intensive phases, 16 (60%) patients developed the symptoms during maintenance chemotherapy, and 4 (15%) after completion of therapy. Isolated anemia was the commonest feature seen in 10 patients (37%) while bicytopenia and pancytopenia were noticed in 8 (30%) and 9 (33%) patients respectively. Fifty percent of patients those who received rituximab (3/6) developed persistent parvoviremia(>4weeks) as compared with 24% (5/21) of those who did not. Two patients (7%) developed hemophagocytic lymphohistiocytosis (HLH). Treatment delay by more than 14 days was encountered in a majority (62%), with 5 patients requiring treatment modification or even suspension. Parvoviral infection in children who are on or have recently completed chemotherapy can lead to multiple cytopenias and significant treatment delays. Rituximab exposure may lead to persistent parvoviral disease (p<0.05). HLH, though occasional, can be a serious complication.

Preoperative Chemoradiation in Carcinoma Esophagus: Experience from a Tertiary Cancer Center in India

Abstract Background: Esophageal cancer is the fourth most common cause of cancer-related deaths in India. In 2012, the CROSS trial evaluated the benefit of induction therapy using weekly carboplatin-paclitaxel with 41.4 Gy radiation versus surgery alone. Pathological complete response (pCR) rates were 28%. Overall survival was improved in the combined therapy arm. However, there is limited data regarding the outcomes of preoperative chemoradiation in Indian scenario. This study was conducted to determine the response to preoperative chemoradiation at a tertiary cancer center in India. Aims: Primary objective was to evaluate the rates of pCR. Secondary objective was to determine recurrence rate and patterns of recurrence. Materials and Methods: We retrospectively reviewed patients with locally advanced esophageal cancer and gastroesophageal junction treated from September 2013 to July 2015. Patients who received preoperative radiotherapy 41.4 Gy with chemotherapy (weekly paclitaxel-carboplatin or cisplatin-5 FU or cisplatin-capecitabine) were included in this study. Chi-square test and Fischer's exact test were used for analysis. Results:: Fifty patients were included in the analysis (76% – squamous cell carcinoma [SCC] and 24% – adenocarcinomas [ACC]). About 60% patients received weekly paclitaxel-carboplatin (CROSS protocol), 32% cisplatin-5 FU, and 8% cisplatin-capecitabine. pCR rate was 39.6%. pCR rate was higher in SCC versus ACC (44.7% vs. 20%) and in paclitaxel-carboplatin than cisplatin-5FU or cisplatin-capecitabine (48.3% vs. 25% vs. 33.3%). At a median follow-up of 12 months, 38 patients were alive, 8 died, and 4 lost to follow-up. Of the 10 patients that recurred, 8 were distant recurrences. Conclusion: Our study results show favorable pCR rate after preoperative CRT with significant higher rate in SCC and patients receiving CROSS regimen. Majority of the recurrences were distant recurrences.

Predictors of Poor Response to Salvage Chemotherapy in Relapsed/ Refractory Pediatric Hodgkin Lymphoma- A Retrospective Analysis from Tertiary Cancer Centre in India

ABSTRACT Background: Previous studies identified prognostic factors for survival in relapsed pediatric Hodgkin lymphoma (HL) who received salvage chemotherapy followed by autologous stem cell transplant (ASCT). However, data regarding predictors of poor response to salvage chemotherapy is limited. Methods: We conducted retrospective study in all relapsed HL treated from January 2003 to December 2013. Logistic regression analysis was done to identify predictors of response to salvage chemotherapy. Cox regression analysis was done to identify prognostic factors for Freedom from treatment failure (FFTF) and overall survival (OS). Results: Forty six patients had relapsed HL. Among 45 patients who received salvage chemotherapy only 34 (73.4%) underwent ASCT. Stage 4 disease (p=0.02) and bulky disease at relapse (p=0.03) were predictors of poor response to salvage chemotherapy. FFTF and OS at 5 yr for entire cohort were 50.1% and 63.3%, respectively, while the same for patients who underwent ASCT were 66.3% and 80.7%, respectively. Among ASCT patients, those who had primary refractory /early relapse [HR-4.7, (95% CI-1, 22); p=0.05] had significant impact on 5 yr FFTF whereas disease status at transplant (CR vs. No CR) had significant impact on 5 yr OS [HR-4.6, (95% CI-1.03, 20.5); p=0.04]. Conclusions: Identification of predictors of poor response to salvage chemotherapy is an unmet need in the management of pediatric HL since complete response (CR) before transplant is independent predictor of survival. Stage 4 and bulky disease at relapse are high risk factors to predict incomplete response. Future trials should explore newer agents for effective salvage for these patients to attain complete response before ASCT.

Trends of Oral Cancer with Regard to Age, Gender, and Subsite Over 16 Years at a Tertiary Cancer Center in India

AbstractIntroduction: Oral cancers are among the most common cancers in the Indian subcontinent and tobacco is the most common implicated etiologic agent for these cancers. Over last two decades, significant changes have occurred in the lifestyle of people in the subcontinent. Antitobacco legislations have made developed and awareness about the harmful effects of tobacco and related products have increased. We hypothesized that this would lead to change in tobacco use pattern and hence impact the trends of oral cancer in India. Methodology: We analyzed the hospital records of patients having buccal mucosa and tongue cancers at a tertiary care cancer center. We noted the trends of patients presenting with these cancers 4 yearly, over a period of 16 years and in this way tried to assess the impact of legislation and awareness activities upon cancer incidence and trends. Results:: This study has shown that the number of patients presenting with tongue and buccal mucosa cancers has not decreased over the years. Increase in buccal mucosa cancers is marginally more than that of the tongue cancer. Proportion of males with respect to females presenting with these cancers has increased. There has been no significant decline in the younger patients presenting with these cancers. Common age of presentation of tongue cancers has come down. Conclusion: The findings of this study highlight the ineffectiveness of current laws and awareness programs in reducing the menace of oral cancer.

Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer.

PurposeThe rapidly increasing burden of cancer in India has profound impacts on health care costs for patients and their families. High out-of-pocket (OOP) expenditure, lack of insurance, and low government expenditure create a vicious cycle, leading to household impoverishment. Complex cancer surgery is now increasingly important for emerging countries; however, little is understood about the macro- and microeconomics of these procedures. After the Lancet Oncology Commission on Global Cancer Surgery, we evaluated the OOP expenditure for patients undergoing pancreatico-duodenectomy (PD) at a government tertiary cancer center in India.MethodsProspective data from 98 patients who underwent PD between January 2014 and June 2015 were collected and analyzed. The time frame for consideration of expenses, including all preoperative investigations, was from the first hospital visit to the day of discharge. Catastrophic expenditure was calculated by assessing the percentage of households in which OOP health payments exceeded 10% of the total household income.ResultsThe mean expenditure for PD by patients was Rs.295,679.57 (US$74,420, purchasing power parity corrected). This amount was significantly higher among those admitted to a private ward and those with complications. Only 29.6% of the patients had insurance coverage. A total of 76.5% of the sample incurred catastrophic expenditure, and 38% of those with insurance underwent financial catastrophe compared with 93% of those without insurance. The percentage of patients facing catastrophic impact was highest among those in semiprivate wards, at 86.7%, followed by those in public and private wards.ConclusionThe cost of PD is high and is often unaffordable for a majority of India’s population. A review of insurance coverage policies for better coverage must be considered.

End-of-Life Treatments in Pediatric Patients at a Government Tertiary Cancer Center in India

The primary objective of this study was to describe demographics and end-of-life treatments of children with cancer at a government tertiary cancer center in India. A retrospective review was undertaken of medical charts of all children younger than 18 years, who died as inpatients while undergoing treatment at the pediatric oncology department between April and September 2016. Data were collected on demographics, diagnosis, treatments, survival, palliative care involvement, and symptoms at end of life. There were 44 pediatric oncology patients who died in the hospital during the study period. The most frequent diagnoses were hematological malignancies (n = 29). Tumor-specific treatment was given to 38/44 (86%) patients in the last 30 days of life, and 13 patients in the last day of life or 1 day before. Of all deaths, 23/44 (52%) occurred within 30 days of admission to the pediatric ward and 34/44 (77%) within 90 days. Of the 44 patients, 25 (57%) were referred to palliative care. The median number of days between referral and death was 14 (0-78) days. Frequent symptoms documented were bleeding (11/44), dyspnea (10/44), pain (7/44), seizures (7/44), and delirium (5/44), with each patient having one or more of these symptoms. Only patients with a palliative care referral received opioid analgesics or benzodiazepines at the end of life. This study highlights the demographics of suffering, death, and end-of-life care in children with cancer at a government tertiary cancer center in India.

Abstract No. 561 Percutaneous endoluminal brush cytology in patients suspected of malignant biliary obstruction: Experience from a tertiary cancer center in India

To evaluate endoluminal brush cytology during percutaneous biliary drainage in patients suspected of malignant biliary obstruction. From January 2010 to December 2016, 106 consecutive patients with obstructive jaundice secondary to suspected malignant biliary obstruction underwent 136 endoluminal brush cytology procedures, during or after percutaneous transhepatic biliary drainage in presence of on-site cytologist. The data was collected retrospectively and analysed. The lesions involved the common bile duct (n-21), common hepatic duct (n-22) and hilum with right or left intrahepatic ducts (n-63). In each patient, upto three (mean-1.3) brush cytology specimens were taken with 8F double lumen brush. Definitive diagnosis in each case was established by the Brush cytology, exploratory laparotomy, biopsy/cytology from any other metastatic site or combination of tumour markers, radiological or clinical suspicion and increase in size or metastasis in follow-up. Statistical analysis was performed using chi-square test and Z-test of significance to compare sensitivity and p-value ≤0.05 was considered statistically significant. 66 out of 106 patients had correct diagnoses of malignancy on brush cytology. 3 diagnoses proved to be true-negative & 37 were false-negative. 9 out of 22 patients (40.1%) had malignancy diagnosed in 2nd attempt and 1 of 3 patients (33.3%) had malignancy diagnosed with 3rd attempt. Diagnostic sensitivity and specificity brush cytology for malignant nature of biliary strictures was 64.1% and 100% respectively with accuracy of 65.1%. The sensitivity of brush cytology was highest in proximal hilar block 67.8% as against 38.5% noted for lower CBD block, this difference was statistically significant (p-value ≤0.034). Anastomotic site recurrence had a sensitivity of 46.1% in diagnosing malignant nature of disease. No complications were related to the procedure. Percutaneous endoluminal brush cytology is relatively accurate procedure that is safe & easy to perform through a transhepatic biliary drainage tract. Sensitivity to diagnose malignant stricture was higher in primary and proximal hilar block as against lower CBD block & anastomotic site strictures.

Outcomes and complications of surgery in patients with intermediate-risk neuroblastoma: experience from an Indian tertiary Cancer Centre.

The treatment of intermediate risk (IR) neuroblastoma has evolved with the focus now on reducing the drugs, dosage, and duration of chemotherapy. The aim of this study is to present the outcomes of treatment and the complications of surgery in patients with IR neuroblastoma treated at a tertiary cancer center in India. All eligible patients with IR neuroblastoma treated between April 2005 and August 2016 were identified. The presence and number of image-defined risk factors (IDRF) before and after neoadjuvant chemotherapy were retrospectively analyzed as were the extent of surgery, complications, and outcomes. Of 282 neuroblastoma patients treated during the study period, 54 had IR neuroblastoma. Complete excision was achieved in 25 patients. There were 26 surgical complications in 22 patients with a similar incidence in patients with complete (n = 13) or incomplete (n = 13) resection (p = 0.78). After a median follow-up of 47 months, the 4-year overall and event-free survival was 91.5% and 75%, respectively. There was no difference in survival between patients who underwent complete resection versus those with incomplete resection (p = 0.9). Outcomes of IR neuroblastoma are favorable. The extent of resection does not affect the survival and complications can occur even when the resection is incomplete.

Buccal Fat Pad a Forgotten Option of Reconstruction in Oral Cancer.

The buccal fat pad (BFP) originally described as an anatomic structure without any obvious function. For long period it was considered to be surgical nuisance. However during the last four decades buccal fat is successively used tool for maxillofacial surgery for reconstruction of small to medium sized acquired or congenital soft tissue and bony defect in oral cavity. The aim of present article is to review the database available regarding BFP including its anatomy, clinical usage in oral malignancy as tool of reconstruction after ablative procedures it's success and its adoptability with other loco-regional flap for oral reconstruction in different scenario and our experience with it in tertiary cancer centre in India.

Hepatoblastoma: 16-years’ experience from a tertiary cancer centre in India

BackgroundHepatoblastoma is a rare pediatric tumor arising from the liver. The present study was conducted to ascertain the clinical profile and survival outcomes of patients with hepatoblastoma treated at our centre. MethodsWe collected the case records of patients with hepatoblastoma treated between January 2000 to December 2016 and analysed the baseline characteristics, treatment details and outcomes. Survival was analysed using Kaplan Meier method. ResultsTwenty-seven patients with hepatoblastoma received treatment at our centre during the study period. Median age of the patients was 12 months and 76% were males. The commonest presenting symptom was abdominal mass and the median Alpha Fetoprotein (AFP) level at the time of diagnosis was 40,000 ng/ml. PRETEXT stage II was documented in 11 and III in 11 patients. High risk disease (PRETEXT IV or metastatic disease or portal venous invasion or AFP < 100 ng/ml) was documented in 8/27 (30%) patients. Neoadjuvant chemotherapy (NACT) was given to 23/27 patients and complete surgical resection was possible in 15/23 (65%) after NACT. Infusional cisplatin and doxorubicin (PLADO) was given in 24/27 patients. Liver transplantation was done in 1 patient. The median follow-up was 51 months and the 5-year overall survival for standard risk and high-risk patients was 78.8% and 40% respectively. ConclusionPatients with standard risk hepatoblastoma have survival outcomes comparable to Western countries, however, outcomes in patients with high risk non-metastatic inoperable disease remains low due to financial constraints in performing liver transplantation. Multimodality treatment including NACT with PLADO based regimens followed by resection is a feasible strategy.