Publications by authors named "Ashish Gulia"

98 Publications

Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions.

J Clin Orthop Trauma 2021 Sep 6;20:101496. Epub 2021 Jul 6.

Assistant Professor (adhoc), Dept of Surgical Oncology, Tata Memorial Hospital, and Homi Bhabha National Institute (HBNI), Mumbai, India.

Most malignant bone tumors are treated with surgical excision, adhering to oncologic principles, followed by reconstruction to preserve form and function whenever feasible. Primary bone tumors around the elbow are rare accounting for <1% of all skeletal tumors. They pose a reconstructive challenge, due to the complex interplay between the osseous & capsulo-ligamentous structures which is essential for elbow stability and function. Tumors affecting the proximal ulna are rare and reconstruction of the defects following these tumors is extremely challenging. Various reconstruction options like arthrodesis, autogenous bone grafts, allografts, re-implantation of sterilized tumor bone, pseudoarthrosis, and endoprosthesis have been tried with variable success. However, due to lack of standardization and the rarity of the site, surgeons are often in a dilemma to choose the correct option. This can lead to suboptimal functional outcomes and long-term failures. In this article, we reviewed the published literature on proximal ulnar tumors and noted the pros and cons of various reconstructive procedures. We have also attempted to formulate reconstruction recommendations based on the level of resection of proximal ulna.
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http://dx.doi.org/10.1016/j.jcot.2021.101496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319519PMC
September 2021

"Rosette forming" Primary high-grade B-cell lymphoma, presenting as a scapular mass, masquerading Ewing sarcoma: A rare case with diagnostic implications.

Indian J Pathol Microbiol 2021 Jul-Sep;64(3):617-619

Surgical Oncology (Bone and Soft Tissues), Tata Memorial Hospital, Parel, HBNI University, Mumbai, Maharashtra, India.

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http://dx.doi.org/10.4103/IJPM.IJPM_468_20DOI Listing
August 2021

Inkk Trial - Intraoperative ketamine for perioperative pain management following total knee endoprosthetic replacement in oncology: a double-blinded randomized trial.

Braz J Anesthesiol 2021 Jul 28. Epub 2021 Jul 28.

Tata Memorial Hospital and Homi Bhabha National Institute, Department of Physiotherapy, Mumbai, India.

Background: There has been a growing interest in the use of ketamine following orthopedic surgeries. We hypothesized that low dose intravenous ketamine during surgery would help in mobilization following total knee replacement (TKR) in oncology patients as assessed by the timed to up and go (TUG) test at 72 hours post-surgery. Our secondary objectives were to compare the opioid requirement at the end of 72 hours, pain scores, satisfaction with pain management, adverse effects, range of joint movement achieved in the post-operative period and the functional recovery at the end of 1 month.

Methods: After the ethics commitee approval, registration of the trial with the Clinical Trial Registry - India (CTRI), and informed consent, this double-blinded trial was conducted. Using computer generated randomization chart, an independent team randomized the patients into ketamine group which received at induction, a ketamine bolus dose of 0.5 mg.kg before the incision followed by 10 µg.kgmin infusion which was maintained intraoperatively till skin closure and the saline group received an equivalent volume of saline. Postoperatively, patient controlled morphine pumps were attached and the pain score with morphine usage were recorded for 72 hours. The TUG tests and range of motion were assessed by the physiotherapists until 72 hours.

Results: Fifty-two patients were enrolled in the trial. Demographics were comparable. No significant intraoperative hemodynamic changes and post-operative adverse events were noted between the groups. A decrease in the TUG test, along with decreased opioid usage with a better range of movements was noted in the ketamine group, but this was not statistically significant. Day of discharge, patient satisfaction score, and functional recovery assessed by Oxford Knee Score (OKS) were comparable between the groups.

Conclusion: In conclusion, low dose intraoperative ketamine infusion does not provide clinical benefit in perioperative pain management and postoperative rehabilitation following total knee endoprosthetic replacement in oncology.
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http://dx.doi.org/10.1016/j.bjane.2021.07.014DOI Listing
July 2021

Desmoid fibromatosis: is the current picture changing?

Future Oncol 2021 Sep 6;17(25):3397-3408. Epub 2021 Jul 6.

Department of Surgical Oncology, Bone & Soft Tissue Service, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, 400012, India.

Desmoid fibromatosis is a locally aggressive tumor with an unpredictable clinical course. Surgery was once the mainstay of treatment, but the treatment protocol has been constantly evolving and currently active surveillance is the front-line approach. There have been significant insights into the molecular biology with the addition of mutational analysis of  adding to prognostic information. We present a review of the literature with current practice guidelines, also including novel therapeutic targets and ongoing clinical trials, to unravel the next step in the management of sporadic desmoid fibromatosis.
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http://dx.doi.org/10.2217/fon-2021-0003DOI Listing
September 2021

Importance of Skeletal Staging in Chondrosarcoma of Bone: Results of Survey on Current Practices Among Musculoskeletal Oncologists.

Indian J Orthop 2021 May 6;55(Suppl 1):234-240. Epub 2020 May 6.

Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, 400012 India.

Purpose: There are no clear guidelines for staging of conventional chondrosarcoma. We conducted an online survey to determine the current practices for skeletal staging for conventional chondrosarcoma among practicing oncologists and to assess any discrepancy in practices and with the published literature.

Methodology: A simple ten-question online survey (e-mails and WhatsApp) was conducted among practicing oncologists over a period of 3 weeks using online portal (surveymonkey.com). It was followed by analysis based on each question to find current practices.

Results: 139 members participated in the survey (84% surgeons, 9% radiologists, 3% medical and 3% radiation oncologists and 1% nuclear medicine). 65% have been treating chondrosarcoma for more than 5 years. 88% opined that biopsy is mandatory even if the radiology is suggestive of a chondrosarcoma. 66% said that solitary skeletal metastasis is seen in less than 2% of the cases but 84% of participants were in favour of performing an investigation (bone scan/PET scan) for skeletal survey. While 43% opined skeletal metastasis is more common in recurrent chondrosarcoma, 26% said that performing a bone scan was likely to impact management, 28% said it will not impact management and 46% were unsure. Of the group who thought that a bone scan would impact management or were unsure, the majority (56%) opined that this was relevant only in grade 2 and grade 3 chondrosarcoma.

Conclusion: There was lack of consensus regarding staging for chondrosarcoma. Only 26% of respondents were convinced that performing a bone scan was likely to impact management of chondrosarcoma. There is a need to analyze large data sets (retrospective/prospective) to arrive at an evidence-based staging algorithm for chondrosarcoma.
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http://dx.doi.org/10.1007/s43465-020-00125-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149512PMC
May 2021

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft.

J Clin Orthop Trauma 2021 Aug 8;19:17-20. Epub 2021 May 8.

Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India.

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.
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http://dx.doi.org/10.1016/j.jcot.2021.04.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144336PMC
August 2021

'Umbrella construct' - an innovative technique for reconstruction of the proximal humerus after curettage in locally aggressive benign bone tumours.

Shoulder Elbow 2021 Apr 10;13(2):188-194. Epub 2020 Jan 10.

Department of Bone and Soft Tissue Tumors, Tata Memorial Hospital, Mumbai, India.

Aim: Reconstructing locally aggressive benign bone tumours of the proximal humerus after intralesional curettage is a challenge. We present a novel reconstruction technique '' where a femoral head and a strut allograft are combined to reconstruct the cavity. Complications, graft incorporation time, functional (Musculoskeletal Tumor Society score [MSTS]) and oncological outcomes were evaluated.

Methods: Between January 2006 and June 2017, 11 cases (10 giant cell tumours, 1 chondroblastoma) underwent curettage followed by reconstruction with Umbrella construct. There were six females and five males with a mean age of 23 years (range 14-36 years). The maximum longitudinal extent of disease was 9 cm (range 5-9 cm).

Results: The median follow-up was 54 months (range 34-122 months). The mean allograft incorporation time was 7 months (5-8 months). One patient had a graft fracture which was managed conservatively. Two cases developed local recurrence and the construct was revised to a prosthesis in both. The mean MSTS score for the nine cases with retained graft was 27 (23-29).

Conclusions: Umbrella construct is an effective reconstruction modality which helps to maintain joint congruity and limb length. It has acceptable oncological outcomes with good function.
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http://dx.doi.org/10.1177/1758573219895988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039762PMC
April 2021

Giant cell tumour of hand bones: outcomes of treatment.

J Hand Surg Eur Vol 2021 09 22;46(7):774-780. Epub 2021 Apr 22.

Orthopaedic Oncology, Tata Memorial Centre & Homi Bhabha National Institute, Mumbai, India.

The purpose of this study was to report the incidence of giant cell tumour of the hand bones in an Asian population, document treatment options and report outcomes of treatment. Of 698 giant cell tumours of bone that underwent surgery between January 2011 and December 2020 at our institute, only 22 (3%) were in the hand. Fourteen occurred in the metacarpals, eight in the phalanges. Fifteen were primary tumours and seven had recurrent disease. Twenty lesions had an associated soft tissue component. Two patients treated for primary disease and one who had been treated for recurrence had local recurrence. Recurrence occurred in two of nine patients treated with curettage, one of three with resection and none of five with ray or digit amputation. Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control. IV.
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http://dx.doi.org/10.1177/17531934211007820DOI Listing
September 2021

Catechism (Quiz 12).

Indian J Pathol Microbiol 2021 Apr-Jun;64(2):439-441

Department of Surgical Oncology (Bone and Soft Tissues), Tata Memorial Hospital (TMH), HBNI University, Parel, Mumbai, Maharashtra, India.

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http://dx.doi.org/10.4103/ijpm.ijpm_41_21DOI Listing
April 2021

Unusual Presentation of Gout as Giant Cell Tumor of Bone: A Case Report.

J Orthop Case Rep 2020 Jul;10(4):17-19

Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

Introduction: Gout is a metabolic disorder known to mimic other disorders. Here is a case report of a patient in which gout was mimicking giant cell tumour of bone.

Case Report: A 48-year-old lady presented with gradually progressive pain and swelling in the right foot. After evaluation with imaging and biopsy, she was counseled that she had giant cell tumor (GCT) of bone and planned for curettage. She chose to have a second opinion, and the biopsy slides were reviewed and the diagnosis of GCT was said to be unlikely based on the appearance under microscope. Gout was suggested as the most probable diagnosis after re-discussion in the tumor board meeting by corroborating clinical, radiological, and pathological findings. The patient was then referred to a rheumatologist, where she responded to medical management.

Conclusion: Gout can present with multiple deceptive symptoms, and the key is to correlate all the factors before coming to a diagnosis.
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http://dx.doi.org/10.13107/jocr.2020.v10.i04.1782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885647PMC
July 2020

Percutaneous Radiofrequency Ablation of Appendicular Skeleton Chondroblastoma-an Experience from a Tertiary Care Cancer Center.

J Vasc Interv Radiol 2021 04 19;32(4):504-509. Epub 2021 Feb 19.

Homi Bhabha National Institute, Anushaktinagar, Mumbai, Maharashtra 400094, India; Orthopedic Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel East, Parel, Mumbai, Maharashtra 400012, India.

Purpose: To evaluate safety and long-term efficacy of radiofrequency (RF) ablation in treatment of chondroblastoma.

Materials And Methods: This retrospective analysis comprised 27 consecutive patients with histopathologically proven chondroblastoma treated by RF ablation. The tumors were located in the proximal humerus (n = 6), proximal tibia (n = 8), proximal femur (n = 6), distal femur (n = 5), acromion process (n = 1), and lunate (n = 1). In 19 patients (70.3%), the tumor was in the weight-bearing area of the bone. Clinical response was assessed by comparing pain scores and functional assessment by Musculoskeletal Tumor Society (MSTS) score before and after ablation. Patients were followed for a minimum of 1 year to rule out complications and recurrence.

Results: Technical success rate was 100%. Mean pain score before the procedure was 7.34 (range, 7-9); all patients experienced a reduction in pain, with 25 (92.6%) patients reporting complete pain relief at 6 weeks. Mean MSTS score before the procedure was 15.4, whereas mean MSTS score at 6 weeks after the procedure was 28.6, suggesting significant functional improvement (P < .0001). Two patients developed osteonecrosis and collapse of the treated bone. There were no recurrences.

Conclusions: Percutaneous RF ablation is a safe and effective option for treating chondroblastoma of the appendicular skeleton.
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http://dx.doi.org/10.1016/j.jvir.2020.07.027DOI Listing
April 2021

Extraskeletal osteosarcomas: current update.

Future Oncol 2021 Mar 3;17(7):825-835. Epub 2021 Feb 3.

Department of Medical Oncology, All India Institute of Medical Sciences, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar East, New Delhi, 110029, India.

Extraskeletal osteosarcoma is a very infrequently diagnosed soft-tissue sarcoma subtype which has identical histological features to bone osteosarcoma. However, its demographics, presentation, radiology and treatment strategy differ from those of osteosarcoma. Its diagnosis can be at times challenging due to radiological and pathological mimics which have more common incidence. A multimodality approach is essential for optimizing the outcomes in extraskeletal osteosarcoma. Although there are certain caveats on inclusion of adjuvant therapies (radiotherapy and chemotherapy), in all cases surgical resection with wide local margins is considered the gold standard for adequate local control. The outcome in advanced disease remains dismal and there is a huge unmet need for prospective studies addressing the optimal treatment strategy. In this article, we review the evidence available for the management of extraskeletal osteosarcoma.
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http://dx.doi.org/10.2217/fon-2020-0802DOI Listing
March 2021

Future Directions in the Treatment of Osteosarcoma.

Cells 2021 01 15;10(1). Epub 2021 Jan 15.

Sarcoma Unit, Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK.

Osteosarcoma is the most common primary bone sarcoma and is often diagnosed in the 2nd-3rd decades of life. Response to the aggressive and highly toxic neoadjuvant methotrexate-doxorubicin-cisplatin (MAP) chemotherapy schedule is strongly predictive of outcome. Outcomes for patients with osteosarcoma have not significantly changed for over thirty years. There is a need for more effective treatment for patients with high risk features but also reduced treatment-related toxicity for all patients. Predictive biomarkers are needed to help inform clinicians to de-escalate or add therapy, including immune therapies, and to contribute to future clinical trial designs. Here, we review a variety of approaches to improve outcomes and quality of life for patients with osteosarcoma with a focus on incorporating toxicity reduction, immune therapy and molecular analysis to provide the most effective and least toxic osteosarcoma therapy.
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http://dx.doi.org/10.3390/cells10010172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829872PMC
January 2021

Giant cell tumors of the sacrum: is non-operative treatment effective?

Eur Spine J 2020 Oct 26. Epub 2020 Oct 26.

Radiation Oncology, Tata Memorial Centre, HBNI, Mumbai, India.

Purpose: Giant cell tumors of sacrum in which surgery could endanger important neural components were treated with short term denosumab, angioembolisation and radiotherapy in different combinations to provide a non-operative function preserving treatment option.

Methods: Between April 2013 and April 2017, 13 sacral GCTs [proximal extent of disease-S1 (10), S2 (2) and S3 (1)] were treated. Age ranged from 20 to 50 years. One patient had loss of bladder control at presentation. Treatment protocol included short term denosumab, angioembolisation and radiotherapy in different combinations. Patients were evaluated every 10-12 weeks. If disease ceased to progress no further treatment was advised. In case of progress, patient was advised additional denosumab and/or angioembolisation and/or radiotherapy till disease stopped progressing.

Results: 10 patients have non-progressive disease and are asymptomatic, 2 have non-progressive disease with occasional pain, 1 patient died. Follow-up duration (since final non-progression of disease) ranged from 15 to 54 months (mean 31 months). Total number of angio embolisation sessions ranged from 0 to 12 (mean = 4), total number of denosumab doses ranged from 5 to 16 (mean = 9). Five patients did not receive any radiotherapy, 5 received 50.4 Gy and one patient each received 50.4 + 30 + 12 Gy, 50.4 + 30 Gy and 50.4 + 12 Gy. The patient with loss of bladder control at presentation recovered. There were no other long-term complications.

Conclusion: This study offers a non-surgical management option that provides good mid-term local control while preserving neurological function in these complex lesions.
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http://dx.doi.org/10.1007/s00586-020-06650-xDOI Listing
October 2020

True Heroes of COVID-19 Battle - Our Nightingales.

Indian J Palliat Care 2020 Jun 30;26(Suppl 1):S184-S185. Epub 2020 Jun 30.

Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

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http://dx.doi.org/10.4103/IJPC.IJPC_204_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534987PMC
June 2020

The Psychosocial Implications on Cancer Patients: The Hidden Collateral of the War on Coronavirus Disease 2019.

Indian J Palliat Care 2020 Jun 30;26(Suppl 1):S126-S129. Epub 2020 Jun 30.

Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

The coronavirus disease 2019 pandemic has evolved into a pandemic of unheard proportions. Given the havoc wreaked by this pathogen worldwide, many countries have adopted an extreme, legally enforced method of social distancing, in the form of a lockdown. Unless appropriate preventive steps are taken, the cost of the pandemic and ensuing lockdown may prove to be irreparable. The evident implications of this lockdown, such as the escalating levels of unemployment, impending economic collapse, and severe food shortage faced by the sudden unemployed migrant labor population, have been widely reported. Cancer patients are a particularly vulnerable group even during nonpandemic times, often presenting late in the course of their disease, without the resources needed to avail recommended treatment. The prevalence of psychiatric complications and emotional distress is significantly higher than in the general population, and the trauma of both the pandemic and subsequent lockdown adds significantly to their mental trauma. This review is aimed toward addressing the problems faced by cancer patients in the face of this pandemic and subsequent lockdown, with a glimpse into possible solutions that can be implemented.
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http://dx.doi.org/10.4103/IJPC.IJPC_203_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534993PMC
June 2020

Case of Atypical Adenoid Hyperplasia of Lung with Polyostotic Fibrous Dysplasia and Diabetes Mellitus: A Random Coincidence or a Possible Unrecognized Syndromic Association?

J Orthop Case Rep 2020 ;10(2):80-83

Department of Surgical Oncology, Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, Maharashtra, India.

Introduction: Fibrous dysplasia (FD) is a benign intramedullary pathologic condition that is characterized by the replacement of bone with fibrous tissue. FD may be monostotic or polyostotic with the craniofacial bones, and the proximal femur is most commonly involved.

Case Report: A 39-year-old lady presented to our hospital, a tertiary care center with asymmetric swelling of her arms, for over 20 years. Radiographs revealed gross enlargement with marrow expansion of the right humerus, scapula with ground-glass matrix, along with a multiseptated cystic appearance. Positron emission tomography-computed tomography screening for the activity of these lesions incidentally demonstrated a few lung nodules, which on biopsy was found to be atypical adenomatous hyperplasia. The lady also had endocrine dysfunction in the form of diabetes mellitus, for which she was on treatment.

Conclusion: In this article, we briefly review the available literature to decipher if any of the associated syndromes with polyostotic FD (being the dominant clinical feature) are known to have associations which explain the above findings. There is a need to recognize the underlying pattern so that appropriate genetic counseling, if any, can be provided to such patients.
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http://dx.doi.org/10.13107/jocr.2020.v10.i02.1708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476696PMC
January 2020

Clinicopathologic, immunohistochemical, molecular cytogenetic profile with treatment and outcomes of 34 cases of Ewing sarcoma with epithelial differentiation, including 6 cases with "Adamantinoma-like" features, diagnosed at a single institution, India.

Ann Diagn Pathol 2020 Dec 9;49:151625. Epub 2020 Sep 9.

Department of Radiation Oncology, Tata Memorial Hospital, Parel Homi Bhabha National Institute(HBNI) University, Mumbai, India.

To analyze clinicopathological features, including treatment profile of 34 cases of Ewing sarcomas with epithelial differentiation, including 6 cases with adamantinoma-like features. EWSR1 gene rearrangement was tested by fluorescence in-situ hybridization. Thirty-four tumors occurred in 19 males and 15 females (M:F = 1.26:1), with age ranging from 7 to 61 years (average = 24.2); in extremities (17), pelvis (5), paraspinal region (6), head and neck region (3), abdomen (2) and lung (1). Prior to molecular testing, 20/34(58.8%) cases were unequivocally diagnosed as Ewing sarcomas. Histopathologically, the most commonly observed pattern was nesting-type, comprising malignant round cells, including adamantinoma-like features, seen in 6 tumors. Immunohistochemically, tumor cells were diffusely positive (cytoplasmic membranous staining) for CD99/MIC2 (34/34), Fli1 (30/30); focally for synaptophysin (4/16) (25%); variably positive for AE1/AE3(31/32)(96.8%), including diffuse immunoexpression in 4 cases; EMA(6/8) and p40(3/8). All 34 (100%) tumors, tested for EWSR1 rearrangement, displayed positive results. According to the treatment details (available in 24/34 cases, 70.5%), most patients (13/24)(54.1%) were treated with surgical resection and a specific chemotherapy(CT) regimen (neoadjuvant or adjuvant settings), including 7 patients, who received adjuvant radiotherapy. During follow-up (16 cases, 47%), 5 patients developed recurrences and 8 developed metastasis, including a single, who developed recurrence. Finally, 10 patients were alive-with-disease (2-22 months); 6 free-of-disease (5-36 months). This constitutes one of the largest documentation of these rare tumors from our subcontinent, which are diagnostically challenging; require molecular confirmation and associated with treatment implications.
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http://dx.doi.org/10.1016/j.anndiagpath.2020.151625DOI Listing
December 2020

Proximal femur sarcomas with intra-articular disease-Do intra-articular resections provide adequate local control?

J Surg Oncol 2020 Dec 25;122(8):1668-1675. Epub 2020 Aug 25.

Department of Surgical Oncology, Bone and Soft Tissue Disease Management Group, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

Background And Objectives: Hip preserving (intra-articular) resections for proximal femur sarcoma have better function compared to peri-acetabular (extra-articular) resections, which are more complex and morbid. But, do intra-articular resections in selected cases with intra-articular disease provide adequate local control?

Method: Extra-articular resection or intra-articular resection in cases without pathologic fracture or away from joint/capsule was classified as a planned safe margin (SM). Circumferential removal of labrum without acetabular resection in cases without gross joint contamination was classified as planned close margins (CM). We analyzed local recurrence-free survival (LRFS) (death as a competing event) for 86 proximal femur resections (SM = 55, CM = 31).

Results: The 5 years LRFS was 84% (n = 6/55, 10%) in the SM group and 67% (n = 4/31, 12%) in the CM group. There was no worsening of local recurrence (LR) in the CM group (subdistribution hazard [sH] = 0.69; 95% confidence interval [CI], 0.21-2.29; P = .56). Poor chemotherapy-induced necrosis predicted worse LR (sH = 0.1; 95% CI, 0.01-0.8; P = .03). Overall survival was 16% (SE 8%) at 5 years with LR vs 64% (SE 7%) without LR (P = .0076).

Conclusion: In proximal femur sarcomas with potential for involvement of the hip joint, a CM in selected cases did not worsen LR; providing an option for avoiding additional morbidity with extra-articular resections.
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http://dx.doi.org/10.1002/jso.26182DOI Listing
December 2020

Sarcoma Care Practice in India During COVID Pandemic: A Nationwide Survey.

Indian J Orthop 2020 Jul 31:1-8. Epub 2020 Jul 31.

Department of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, India.

Background: Amidst the COVID-19 pandemic, management of cancer has been one of the most intensely debated topics across the globe. We conducted an online survey to determine the consistency/or the lack of it, in the management of sarcoma patients between centres and the changes in policies.

Methods: A twenty-five question online survey was conducted among practicing physicians over a period of 10 days using online portal (surveymonkey.com). It was followed by a critical analysis based on responses to each question.

Results: Of 194 medical professionals who participated, 80% were surgeons and 53% were working in government institutes. Most respondents (81%) continued their practice with some modifications. In OP majority (67%) relied only on symptom, contact enquiry and temperature recording for screening. COVID-19 testing was done more (43%) in IP patients. Most of institutes (83%) followed rotational policy to reduce the number of staff at risk while 57% offered an alternate accommodation. 52.3% continued chemotherapy for all patients while radiotherapy for all was offered by 45%. In metastatic cases, majority preferred either no treatment or non-surgical intervention (71%).84.5% believed in adapting changes (42%-avoid supra major surgeries, 27%-Operating only emergency cases and 15.5%-High grade sarcomas with curative intent) in surgical management of sarcomas. For benign bone tumors, majority (71%) agreed on adapting changes while 25% agreed on deferring all cases. 69% preferred teleconsultations for follow-up. Complete PPE were being used for all aerosol generating procedures by 44%. Only two thirds agreed with their institutes policy of PPE usage and COVID-19 testing.

Conclusion: This survey has highlighted disparity on COVID-19 screening and management in various institutes across the country. This will act as a reference point for tracking future trends in bone and soft tissue tumor management guidelines, as the COVID-19 scenario unfolds globally and particularly in India.
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http://dx.doi.org/10.1007/s43465-020-00206-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393016PMC
July 2020

Adapting Management of Sarcomas in COVID-19: An Evidence-Based Review.

Indian J Orthop 2020 May 30:1-13. Epub 2020 May 30.

Department of Radiology, Tata Memorial Hospital, and Homi Bhabha National Institure (HBNI), Mumbai, India.

With the novel coronavirus disease (COVID-19) being declared a global pandemic by the World Health Organization, the Indian healthcare sector is at the forefront to deliver optimal care. Patients with cancer especially are at serious risk for increased chances of morbidity and mortality due to their immunocompromised state. Currently there is a paucity of definitive guidelines for the management of sarcomas during the pandemic in a resource-constrained and diverse population setting like India. Health care professionals from various specialties involved in the management of sarcomas have collaborated to discuss various aspects of evidence-based sarcoma management during the COVID-19 pandemic. This article provides structured recommendations for HCP to adapt to the situation, optimize treatment protocols with judicious use of all resources while providing evidence-based treatment for sarcoma patients.
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http://dx.doi.org/10.1007/s43465-020-00143-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261215PMC
May 2020

Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic.

J Surg Oncol 2020 Nov 3;122(6):1013-1019. Epub 2020 Aug 3.

Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.

Background: Health care workers (HCWs) are at risk of getting infected while at work, for example, operating room (OR), hence it is pertinent that they don all the appropriate personal protective equipment (PPE) to minimize the chance of getting infected.

Methods: A COVID-19 specific briefing and debriefing form was created and used in the OR along with the World Health Organization surgical safety checklist to reinforce the use of appropriate PPE. An audit was subsequently done to understand the compliance to PPE use, followed by a survey based on the findings of the audit to understand the issues related to noncompliance.

Results: The form was used in 183 out of the 238 (77%) surgeries performed during a months' time. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for eye protection (45/567) (P = .01). The survey revealed that this was mostly among surgeons mainly due to discomfort, poor visibility, and frequent fogging.

Conclusions: Our HCW were adapting well to the new normal of donning appropriate PPE in the OR, except for the eye protection due to discomfort and visibility related issues. This is important to know so that necessary changes could be introduced to better the compliance.
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http://dx.doi.org/10.1002/jso.26151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436474PMC
November 2020

High Response Rates and Promising Outcomes of Patients with Relapsed Ewing Sarcoma, Especially in Adolescents and Young Adults Treated on a Novel Hybrid Salvage Chemotherapy Regimen.

J Adolesc Young Adult Oncol 2021 04 20;10(2):185-192. Epub 2020 Jul 20.

Bone and Soft Tissue Disease Management Group and Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India.

About 30%-35% of nonmetastatic and 60%-80% of metastatic Ewing Sarcoma (ES) will relapse post-treatment and outcomes after relapse continue to be poor over last several decades. Prognostic factors affecting survival after relapse of ES are also not robustly known. We present outcomes using a novel hybrid salvage protocol of four active chemotherapeutic agents in our cohort of patients after relapse of ES. This is a retrospective analysis of all consecutive relapsed ES patients treated with curative intent over 4 years (January 2012 to December 2015). All received 12-cycles of hybrid chemotherapy regimen with surgery/radiotherapy done after first 4 cycles. Event-free survival (EFS)/overall survival (OS) estimates were analyzed by Kaplan-Meier product-limit estimator. Cox regression analysis was performed to identify prognostic factors predicting outcome in relapsed ES. Salvage regimen was given to 53/108 relapsed ES patients with the rest having opted for palliation upfront. Median age of the treated patients was 19 years (range: 4-40); male:female ratio was 2.7:1. Median time to first relapse was 18.8 months (range: 2.2-91). While 41/53 patients (77%) completed salvage therapy, 6 (11.3%) progressed and 6 (11.3%) abandoned treatment. Median follow-up of the study cohort is 31 months (range: 4-81). Of the analyzable cohort ( = 47), 30 (64%) had a second relapse or progression on salvage treatment. At last follow-up, 31 patients had died (including one due to toxicity and rest due to disease) and 16 patients were alive (14 with no active disease and 2 with disease). The 4-year EFS and OS are 28% and 37%, respectively, for the entire cohort. While adolescents and young adult patients (AYA) had a better survival (-0.041), relapsed ES patients with shorter disease-free interval (DFI) (<24 months) had a poorer survival (-0.004). The type of relapse (local or metastatic or combined) after primary treatment did not affect outcome after salvage therapy. We have used a novel hybrid chemotherapy protocol using four active agents in relapsed ES, which is well tolerated and shows promising results. Older age (≥15 years) and longer DFI (>24 months) portend better survival post-relapse. In our cohort of relapsed ES, AYAs fared better than others and type of relapse after primary treatment did not affect outcome after salvage therapy.
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http://dx.doi.org/10.1089/jayao.2020.0016DOI Listing
April 2021

Outcomes with nondose-dense chemotherapy for Ewing sarcoma: A practical approach for the developing world.

Pediatr Blood Cancer 2020 11 24;67(11):e28604. Epub 2020 Jul 24.

Department of Pediatric Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.

Background: The current multidisciplinary approach in the treatment of Ewing sarcoma has improved cure rates, with contemporary dose-dense chemotherapy attaining 5-year event-free survival (EFS) of 73% in localized cases. Dose-intense and dose-dense chemotherapy is difficult in the majority of resource-limited settings with limited access to optimal supportive care. We report on patients with Ewing sarcoma treated on EFT-2001, a nondose-dense chemotherapy protocol.

Procedure: A retrospective analysis was conducted of patients (<15 years) with Ewing sarcoma treated with curative intent during January 2013-June 2017 with an institutional ethics committee-approved nondose-dense protocol (EFT-2001). Local therapy was planned after 9-12 weeks of chemotherapy with metastatic sites addressed with radiotherapy. The study assessed outcomes and prognostic factors.

Results: We analysed 200 patients with M:F ratio of 1.27:1 and metastases in 41 patients (20.5%). At a median follow up of 41.5 months (range 4.5-81.8 months), respective 3-year EFS and overall survival (OS) of the whole cohort is 65.3% (95% confidence interval [CI]: 58.1-71.7%) and 79.3% (95% CI: 72.8-84.5%); for localized and metastatic cohort, 70.9% (95% CI: 62.9-77.5%) and 82.8% (95% CI: 75.7-89.0%); and for metastatic cohort, 42.8% (95% CI: 28.0-58.6%) and 65.3% (95% CI: 47.7-78.3%). Presence of residual disease (morphologic/metabolic) on positron emission tomography-computed tomography scan done 3 months post definitive radiotherapy (hazard ratio [HR] 7.92 [95% CI: 3.46-18.14]) and delay in any form of local control >4 months (HR 3.42 [95% CI: 1.32-8.89]) affected outcomes. Nonrelapse mortality during treatment was 6.5%, mainly due to cardiomyopathy (3.0%) and bacterial sepsis (1.5%). Cardiotoxicity was seen in 11.5% of patients.

Conclusions: Nondose-dense chemotherapy provides good outcomes with manageable toxicities in a multidisciplinary treatment approach, while reducing cumulative drug exposures in the developing world where dose-intense or dose-dense chemotherapy could potentially increase toxicity, and hence seems a feasible approach in resource-limited settings. Presence of any residual disease post definitive radiotherapy or delay in local control portends poor outcome.
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http://dx.doi.org/10.1002/pbc.28604DOI Listing
November 2020

Is Skeletal Imaging Essential in the Staging Workup for Conventional Chondrosarcoma?

Clin Orthop Relat Res 2020 11;478(11):2480-2484

A. Gulia, V. Kurisunkal, A. Puri, N. Purandare, S. Gupta, V. Rangarajan, Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, India.

Background: Staging of a bone sarcoma before initiating treatment helps orthopaedic oncologists determine the intent of treatment and predicting the prognosis. As per National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) guidelines, there are no exclusive recommendations for chondrosarcoma staging. They are staged similar to other bone sarcomas even though skeletal metastases are extremely rare in chondrosarcomas.

Questions/purposes: We asked: (1) What proportion of patients with a chondrosarcoma present with detectable only skeletal metastasis? (2) What proportion of patients with chondrosarcoma present with skeletal metastasis with or without concurrent pulmonary metastases?

Methods: Between January 2006 to December 2017, 480 patients with histology-proven chondrosarcomas of the extremity, including clavicle, scapula, spine, and pelvis, presented to our institute. Fifty-three patients were excluded due to incomplete details about their staging. The remaining 427 were retrospectively analyzed and included in this study. Their clinical, radiological, and histopathological details were retrieved from patient files and electronic medical records. Of the 427 patients included, 53 had Grade 1 chondrosarcoma, 330 had Grade 2 chondrosarcoma, and 41 had Grade 3 chondrosarcoma. Grade was not available in three patients. All patients were staged with a thoracic CT scan and bone scan or a whole body fluorodeoxyglucose positron-emission tomography/CT (FDG PET/CT). Patients with a suspected or documented metastasis were reviewed again by an experienced radiologist and a nuclear medicine expert for the purpose of this study. A total of 8% (35 of 427) of patients with chondrosarcoma had isolated lung metastases at the time of initial staging. These included 9% (31 of 330) of patients with Grade 2 chondrosarcomas and 10% (4 of 41) of patients with Grade 3 chondrosarcomas. No patient with a Grade 1 chondrosarcoma had detectable lung metastases. The primary study endpoint was the number of patients who had a diagnosis of skeletal or skeletal and lung metastases as identified by the staging modalities.

Results: Three patients with Grade 2 chondrosarcoma had only skeletal metastasis. No patients with Grade 1 or Grade 3 chondrosarcoma had detectable bone metastases. Combined lung and bone metastases were seen in only two patients with Grade 2 chondrosarcoma.

Conclusions: Our study found that the incidence of bony metastasis in conventional chondrosarcomas is extremely low. Considering the present results, we believe skeletal scanning may be overused in current staging algorithms. We do not have survival outcomes to know if detecting these few patients with skeletal lesions at initial presentation would be important in the absence of symptoms, but our data suggest that omitting skeletal imaging from the staging work-up of conventional chondrosarcomas should be considered. It may be reserved for patients with documented pulmonary metastases.

Level Of Evidence: Level IV, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594919PMC
November 2020

Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy.

Ann Surg 2020 09;272(3):e249-e252

Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Ernest Borges Marg, Parel, Mumbai, India.

Background: Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots.

Methods: A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020.

Findings: Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV - VI).Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in <60 years (P = 0.169). The median hospital stay was 1 to 9 days across specialties.Postoperatively, 26 patients were tested for COVID 19 and 6 tested positive. They all had higher grade surgeries but none required escalated or intensive care treatment related to COVID infection.

Interpretation: A combination of scientific and administrative rationale contributed to favorable outcomes after major elective cancer surgeries. These results support the continuation of elective major cancer surgery in regions with Covid 19 trends similar to India.
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http://dx.doi.org/10.1097/SLA.0000000000004116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299113PMC
September 2020

Is minimal reconstruction (meshplasty) adequate to restore ankle function after excision of distal fibula tumors?

J Clin Orthop Trauma 2020 May-Jun;11(3):467-470. Epub 2020 Apr 9.

Dept of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, India.

Background: Reconstruction modalities described after distal fibula resection varies from no reconstruction to size matched allograft or reconstruction with ipsilateral proximal fibula. Every procedure has their own limitation. We used Prolene mesh to reconstruct lateral restraint (Meshplasty) after distal fibulectomy.

Question: Is a minimal reconstruction using prolene mesh (meshplasty) adequate to restore ankle stability and function post distal fibula resection?

Method: This retrospective analysis was performed in patients who underwent distal fibulectomy at the tertiary cancer hospital in India, between 01/01/2006 and 31/12/2016. Distal fibulectomy was performed through standard lateral approach. A prolene mesh was anchored to distal tibia and talus using screws or Ethibond sutures. Rehabilitation protocol included below knee cast for 6 weeks followed by gradual full weight bearing mobilization and ankle range of motion. Total 9 patients with mean age of 25 years (range: 13-43) got operated for distal fibulectomy during this period. Mean resection length was 13.3 cm (range: 9-20).

Results: Seven patients were available for final assessment at a median follow-up duration of 78 months (range: 34-161 months). Two patients developed local recurrence. Two patients developed distant recurrence both died of disease. One patient of GCT developed local recurrence in soft tissue at 30months, which was excised. Another patient of OGS developed local recurrence after 8 months along with distant recurrence. One patient of PNET developed distant recurrence at 3 months. One patient had a valgus deformity at 55 months follow up without any restriction of activity while the others had a stable ankle without any deformity. The mean MSTS score was 28 (24-29).

Conclusion: "Meshplasty" after distal fibulectomy is an easy, reproducible, time and cost effective reconstruction modality with minimal complications. It adequately restores ankle function while providing results comparable to other procedures.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jcot.2020.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211805PMC
April 2020

Phosphaturic Mesenchymal Tumors from Head to Toe: Imaging Findings and Role of the Radiologist in Diagnosing Tumor-Induced Osteomalacia.

Indian J Orthop 2020 Apr 13;54(2):215-223. Epub 2020 Jan 13.

4Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, India.

Background: This study aimed at evaluating the imaging findings of phosphaturic mesenchymal tumors and tumor-induced osteomalacia and assess the clinical and biochemical profiles of patients with tumor-induced osteomalacia.

Materials And Methods: Imaging findings in six patients with tumor-induced osteomalacia and histopathologically proven phosphaturic mesenchymal tumors were evaluated. Clinical and biochemical profiles of these patients were also assessed.

Results: Along with having a characteristic biochemical profile, patients with phosphaturic mesenchymal tumors also have certain imaging findings which can aid in the diagnosis such as increased uptake on DOTA PET-CT and homogeneous post-contrast enhancement on CT and MRI.

Conclusion: Patients with tumor-induced osteomalacia have characteristic symptoms, imaging and biochemical profiles. For radiologists, raising the suspicion of a phosphaturic mesenchymal tumor in patients with refractory hypophosphatemic osteomalacia as well as localizing the tumor on imaging is crucial, as complete excision of the tumor leads to resolution of the osteomalacia and the patient's clinical symptoms.
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http://dx.doi.org/10.1007/s43465-019-00005-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096593PMC
April 2020

Principles of Management of Spine Metastasis.

Indian J Orthop 2020 Apr 31;54(2):181-193. Epub 2020 Jan 31.

Orthopaedic Oncology, Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, India.

Background: With evolution of medicine, radiation therapy and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. The most common site of skeletal metastases from other primary malignant neoplasms is the spine, hence, understanding the epidemiology of metastatic spine disease and its presentation is essential for developing a diagnostic and treatment strategy which eventually results in optimum care to reduce disease-related morbidity.

Purpose: With this review article we intend to describe an evidence-based review on the presentation, diagnosis and treatment of metastatic spinal disease.

Methods: We reviewed the current available literature on management of spinal metastasis and have described a step wise evaluation and management strategy of metastatic spine disease.

Conclusion: The present review article addresses various aspects and related controversies related to evaluation, staging and treatment options in the management of spinal metastasis.
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http://dx.doi.org/10.1007/s43465-019-00008-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096601PMC
April 2020

Rare aneurysmal bone cysts: multifocal, extraosseous, and surface variants.

Eur J Orthop Surg Traumatol 2020 Aug 27;30(6):969-978. Epub 2020 Feb 27.

Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padua, Italy.

Multifocal, extraosseous, and surface aneurysmal bone cysts are rare variants of the primary lesions. The clinicopathological features are similar, and the optimal treatment is surgical. Although local recurrences may occur, the prognosis is excellent. This review article introduces the readers to a rare diagnosis which they may have been previously unfamiliar with, presents the clinicopathological and imaging features of these rare aneurysmal bone cyst variants, and discusses their diagnosis and treatment. The clinicians who treat patients with aneurysmal bone cysts should be familiar with these uncommon entities and their differential diagnosis.
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http://dx.doi.org/10.1007/s00590-020-02640-3DOI Listing
August 2020
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