Radio-guided occult lesion localization for nonpalpable suspicious breast lesions: A novel technique

Background : Breast screening programs and increased self-awareness has led to increased identification of early breast cancers. Up to 25% of mammographicaly identified lesions are nonpalpable, which require a precise technique to localize and excise completely. Radio-guided occult lesion localization (ROLL) is a technique, which uses hand held gamma probe to accurately localize and completely excise occult beast lesions. ROLL can also be combined with sentinel lymph node biopsy (SLNB) for early breast cancers. This is a minimally invasive approach with least morbidity and better patient compliance. Materials and Methods : 25 cases underwent ROLL for nonpalpable breast lesions. 99m Tc-sulphur colloid was injected into the center of the lesion under ultrasound guidance preoperatively. No guidewire localization was performed. Under general anesthesia, surgical excision of the lesion was carried out using the hand-held gamma probe. Fifteen patients were diagnosed with early breast cancer with clear margin status. These patients also underwent SLNB at the same procedure. Results : Fifteen out of 25 cases were found to harbor invasive breast cancer. The pathological margins were clear of tumor in all of these patients. The sentinel node was identified in all cases. In four out of the 15 cases, sentinel node harbored occult metastases. Conclusion : ROLL is a useful method for precise, three-dimensional localization of impalpable breast tumors with results comparable to those achieved by surgery of palpable lesions. Furthermore, ROLL is feasible in connection with sentinel node biopsy in the same setting. It is performed as a day-care procedure with good cosmesis

Anaesthetic management of extra-pleural pneumonectomy and hyperthermic intrathoracic chemotherapy procedure

Malignant pleural mesothelioma is a rare tumour with survival of 9-17 months after diagnosis. Radical surgical resection by extra-pleural pneumonectomy combined with hyperthermic intrathoracic chemotherapy has shown to improve patient survival and better microscopic tumour control. Anaesthetic management of this procedure is challenging due to the complex pathophysiological changes associated with prolonged duration of surgery, one- lung ventilation, haemodynamic instability due to major blood loss, temperature variations including heat loss during pneumonectomy and rapid rise in temperature during hyperthermic chemotherapy, cardiac arrhythmias due to exposure to heated chemotherapeutics, cisplatin toxicity and acid-base changes. Intra-operative management involves protective ventilation, regulation of temperature and haemodynamics along with prevention of complications associated with ′heated chemotherapeutics′. Thorough pre-operative assessment and preparation, advanced intra-operative monitoring with prompt corrective interventions, will help in improved patient outcome in the immediate post-operative period. We present one such case done for the 1 st time in India

Radio-guided occult lesion localization for nonpalpable suspicious breast lesions: A novel technique

Background : Breast screening programs and increased self-awareness has led to increased identification of early breast cancers. Up to 25% of mammographicaly identified lesions are nonpalpable, which require a precise technique to localize and excise completely. Radio-guided occult lesion localization (ROLL) is a technique, which uses hand held gamma probe to accurately localize and completely excise occult beast lesions. ROLL can also be combined with sentinel lymph node biopsy (SLNB) for early breast cancers. This is a minimally invasive approach with least morbidity and better patient compliance. Materials and Methods : 25 cases underwent ROLL for nonpalpable breast lesions. 99m Tc-sulphur colloid was injected into the center of the lesion under ultrasound guidance preoperatively. No guidewire localization was performed. Under general anesthesia, surgical excision of the lesion was carried out using the hand-held gamma probe. Fifteen patients were diagnosed with early breast cancer with clear margin status. These patients also underwent SLNB at the same procedure. Results : Fifteen out of 25 cases were found to harbor invasive breast cancer. The pathological margins were clear of tumor in all of these patients. The sentinel node was identified in all cases. In four out of the 15 cases, sentinel node harbored occult metastases. Conclusion : ROLL is a useful method for precise, three-dimensional localization of impalpable breast tumors with results comparable to those achieved by surgery of palpable lesions. Furthermore, ROLL is feasible in connection with sentinel node biopsy in the same setting. It is performed as a day-care procedure with good cosmesis

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

Abstract Amit Rauthan 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

An Overview of Experience with Preoperative Skin Marking and Clip Insertion in Non-palpable Breast Cancer Lesions in a Tertiary Care Cancer Center and Its Impact on Breast Conservation Surgery

Newer adjuncts in breast conservation surgery are striving for more precise excision of these cancerous lesions. This study evaluates two such techniques, preoperative ultrasound-guided lesion clipping and skin marking, and their effects on the surgical outcomes of early breast cancer lesions undergoing breast conservation surgery. This retrospective study includes 56 consecutive patients with non-palpable (upfront or post-neoadjuvant chemotherapy) biopsy-proven early breast cancers (T1, T2, T3 lesions). These patients underwent breast conservation surgery using ultrasound-guided percutaneous clipping and skin marking techniques at Manipal Comprehensive Cancer Center, between January 2019 and May 2021. Post excision, their total specimen volume and tumor volume were studied. Of the total of 56 patients, based on institutional protocol, 33 were clipped before neoadjuvant chemotherapy, and 23 patients underwent skin marking. Mean specimen volume was 99.25 ± 60 cm3, and mean tumor volume was 7.38 ± 13.6 cm3. Forty-seven patients (84%) were managed with a simple local type I oncoplastic procedure. In nine patients (16%), local perforator-based flap reconstruction was done. These techniques help to achieve precise excision of these tumors, requiring a lower volume of resection to achieve negative margins, with better cosmetic outcomes