Sandeep Bhoriwal

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with significant morbidity. Enhanced Recovery After Surgery (ERAS) protocols may improve perioperative outcomes, but data from low‐ and middle‐income countries (LMICs) remain limited. Methods: We conducted an ambispective study comparing patients undergoing CRS–HIPEC before (January 2015–June 2022; n = 294) and after (July 2022–June 2024; n = 70) ERAS implementation at a high‐volume tertiary cancer centre. ERAS compliance and perioperative outcomes, including length of stay (LOS), major morbidity (Clavien–Dindo III–IV), mortality, readmission, and reoperation, were analysed. Results: Overall, ERAS compliance was 77.1%. Compliance was highest for preoperative and intraoperative components, while postoperative elements showed comparatively lower adherence. Median postoperative LOS decreased significantly from 8 to 5 days ( p = 0.02). Major morbidity declined from 20.1% to 12.9%, although this was not statistically significant. Ninety‐day mortality (4.6% vs 4.3%), readmission (15% vs 12.9%), and reoperation rates (13% vs 10%) were comparable between groups. Conclusion: Implementation of an ERAS pathway for CRS–HIPEC in a high‐volume LMIC centre is feasible and safe, resulting in shorter hospital stay without increasing morbidity or mortality.

PURPOSE: Radiation-associated sarcomas (RAS) are rare tumors developing in previously irradiated areas. Most data come from high-income countries, with limited reports from low- and middle-income countries (LMICs). To our knowledge, this is the largest RAS cohort from India, examining clinical features, genetic predisposition, systemic therapies, and outcomes, in a resource-limited setting. MATERIALS AND METHODS: We conducted a retrospective analysis of a sarcoma database at AIIMS, New Delhi, from January 2015 to June 2025. Patients ≥18 year with biopsy-confirmed RAS, meeting modified Cahan criteria, were included. RESULTS: Twenty-three patients (0.32% of 7,138 sarcoma cases evaluated) were diagnosed with RAS. The median age at diagnosis was 51.1 years, with a median latency of 13.25 years following radiotherapy. Breast cancer was the most common antecedent malignancy (21.7%). Soft tissue sarcomas were predominant (14, 60.9%), with undifferentiated pleomorphic sarcoma (8, 34.8%) being the most frequent histologic subtype. At presentation, 12 patients (52.2%) had metastatic disease, while three (13.1%) had locally unresectable tumors. The majority of tumors were high-grade (20, 87.0%), with a median tumor size of 6.9 cm. Among eight patients with resectable disease, seven underwent surgery, achieving R0 resection in 62.5% of cases. Re-irradiation was performed in three patients (13.0%). Sixteen patients (69.6%) received systemic therapy: 12.5% had partial response, 25% had stable disease, and two patients on immunotherapy had progressive disease. At a median follow-up of 68.2 months, the median overall survival was 59.2 months and 13.4 months for patients with nonmetastatic and metastatic disease, respectively. CONCLUSION: Despite large, high-grade, and advanced tumors, curative surgery was feasible in most nonmetastatic cases, and systemic therapies were widely used. The favorable survival outcomes underscore the importance of centralized, multidisciplinary sarcoma care in LMICs. Lack of immunotherapy responses calls for investigation into resistance mechanisms and histology-specific treatments.

Gastroesophageal junction (GEJ) cancers have shown a rising global incidence, with unique anatomical and biological features distinguishing them from esophageal and gastric carcinomas. This study evaluates the clinicopathological characteristics, treatment modalities, survival outcomes, and recurrence patterns of GEJ cancers in an Indian population. This study was conducted on 107 patients with histologically confirmed GEJ carcinoma treated at a tertiary cancer center in India between 2012 and 2024. Demographic, clinical, radiological, surgical, and survival data were reviewed. Staging was based on endoscopy and contrast-enhanced CT. Multimodality treatment strategies were implemented, including neoadjuvant chemoradiotherapy (CROSS), chemotherapy (FLOT), and definitive chemoradiotherapy for unresectable cases. Survival was analyzed using Kaplan–Meier methods, and predictors of recurrence were assessed using Cox regression. The cohort had a male-to-female ratio of 3.45:1 with a mean age of 53 years. Adenocarcinoma was the predominant histology (63.6%). Curative resection was achieved in 79.4%, with an R1 rate of 2.4%. The most common surgical approach was Ivor Lewis esophagectomy (63.6%). The 2-, 3-, and 5-year disease-free survival (DFS) rates were 82%, 75%, and 56%, respectively; overall survival (OS) rates were 88%, 77%, and 59%. Recurrence occurred in 35.3% of patients, predominantly systemic. On multivariate analysis, lympho-vascular invasion, extent of lymphadenectomy, and pathological stage significantly predicted recurrence. Gastroesophageal junction cancers in India predominantly affect middle-aged males and are mostly adenocarcinomas. Multimodality treatment, including neoadjuvant therapy and extended lymphadenectomy, shows promising survival. However, systemic recurrence remains a major challenge. Early detection, personalized treatment, and standardized follow-up are essential to improve outcomes. These findings highlight the urgent need for resource-sensitive national strategies to tackle the rising burden of GEJ cancers.

Minimally invasive esophagectomy is gaining popularity. Comparative outcomes from open vs minimally invasive esophagectomy are reported sparsely from India. The current study is a retrospective analysis comparing early post-operative and long-term oncological outcomes among the open and minimally invasive approaches for esophagectomy. Three hundred thirteen patients were analysed, 194 from the open group (OG) and 119 in the minimally invasive group (MIE). Morbidity to the extent of Clavin Dindo level III and more among the two groups were statistically higher 52/194(27.83%) in the OG vs the MIE 21/119(17.6%), p = 0.043. Early postoperative complications, including arrhythmia, air leak from lung or bronchial injury, chyle leak, and recurrent laryngeal nerve injury, were not significantly different among the two groups. Pneumonitis and anastomotic site leak were significantly more in the OG vs the MIS group, 14 (7.21%) vs 4(3.36%) p-value of 0.039 and 18(9.28%) vs 5(4.20%) p = 0.030, respectively. Early postoperative outcomes in terms of hospital stay, ICU stay, and blood loss were significantly less in MIE vs OG, with a p-value of 0.0035, 0.002 and 0.001, respectively. The median follow-up was 47 months. Three-year mortality rates in the two groups were statistically similar (32.6%) in the OG and (37.2%) in the MIE is (P = 0.621). Three-year disease-free survival (DFS) in the OG was 62.2%, and the MIE was 73.6%. (p = 0.221). Three-year overall survival (OS) of esophagectomy in the OG was 78.8%, and the MIE was 80.9%, (p = 0.727).

Background: Trace elements and heavy metals play crucial roles in various biological activities, but disproportionate amounts are linked to several diseases, including malignancies. This study aimed to identify and quantify the concentrations of heavy metals and trace elements in the blood and urine of patients with gallbladder cancer (GBC) and gallstone disease (GSD). Materials and Methods: This observational study included patients with radiologically proven GBC and GSD as the study group, with age and sex-matched healthy volunteers as the control group. Blood and urine samples were analyzed for Magnesium, Titanium, Vanadium, Chromium, Manganese, Iron, Cobalt, Nickel, Copper, Zinc, Arsenic, Selenium, Strontium, Silver, Cadmium, Antimony, Mercury (201), Mercury (202), Thallium, and Lead levels using inductively coupled plasma mass-spectroscopy. Results: A total of 80 cases (35 GBC, 35 GSD, 10 controls) were recruited in the study. It was observed that the blood and urinary concentrations of chromium were significantly higher in GBC patients as compared to GSD patients and control, whereas manganese and zinc levels were higher in patients with biliary pathology (GBC and GSD). Arsenic and antimony levels were lower in patients with biliary pathology as compared to control group. Conclusion: This study concludes that there is significant association of metals such as Chromium, Manganese and Zinc, with GBC and GSD. However, larger trials with increased sample size and follow-up were needed to establish the causal relationship with heavy metals and GBC as well as GSD.

Background Post-mastectomy pain Syndrome (PMPS), characterized by chronic neuropathic pain stemming from intercostobrachial nerve lesions, presents a formidable clinical challenge. With the incidence of breast cancer surging, effective interventions for PMPS are urgently needed. To address this, we conducted this double-blind, placebo-controlled, randomized clinical trial to study the efficacy of repetitive Transcranial Magnetic Stimulation (rTMS) therapy over the motor cortex on pain, quality of life and thermal sensitivity in PMPS patients. Methods We delivered 15 rTMS sessions over three weeks in a cohort of 34 PMPS patients. These patients were allocated randomly to either rTMS therapy or sham therapy groups. Pain assessments, utilizing the Visual Analogue Scale (VAS) and Short Form McGill Pain Questionnaire (SF-MPQ), alongside quality-of-life evaluations through the Functional Assessment of Cancer Therapy-Breast (FACT-B), were recorded before and after the 15 sessions. Additionally, we assessed thermal sensitivity using Quantitative Sensory Testing (QST). Results Our findings demonstrate the superior efficacy of rTMS therapy (over sham therapy) in reducing VAS and SF-MPQ scores (p < 0.0001), improving physical (p = 0.037), emotional (p = 0.033), and functional well-being (p = 0.020) components of quality of life, as quantified by FACT-B. Our investigation also unveiled marked enhancements in thermal sensitivity within the rTMS therapy group, with statistically significant improvements in cold detection threshold (p = 0.0001), warm detection threshold (p = 0.0033), cold pain threshold (p = 0.0078), and hot pain tolerance threshold (p = 0.0078). Conclusion The study underscores the profound positive impact of rTMS therapy on pain, quality of life, and thermal sensitivity in patients having PMPS, opening new avenues for pain management strategies.

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study’s mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25–8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries.