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CASE DESCRIPTION

Umesh Kumar is a young 36-year-old gentleman survived by wife and a 3-year-old daughter. He presented with a diagnosis  of recurrent abdominal DFSP associated  with the sarcomatous transformation of Right iliac fossa Retroperitoneal mass and solitary lung metastasis. He presented to us with symptoms of extreme distress and inability to walk. He was evaluated with imaging showing  recurrent large right pelvic retroperitoneal mass abutting iliac bone, femoral vessels and femoral nerve involvement. He had taken multiple opinions and was declared palliative in view of disease involving femoral vessels associated with high morbidity. He was feeling helpless as he was the only earning member and was tailor by profession.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Psychosocial support given priority

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID
We had a multidisciplinary joint clinic meeting and finally decided to offer a single agent 6 cycles of Doxorubicin and reassess. After 2 cycles of chemotherapy, to our surprise, his walking disability was controlled. He started gaining confidence with our treatment and counseling. After 6 cycles we did a response assessment FDG PET CT scan which showed a partial response and amenable to surgery. After discussion & counseling, we planned for surgery and he underwent Retroperitoneal mass excision with periosteum stripping and femoral nerve segmental resection and reconstruction. During postoperative care, he recovered well with aggressive rehabilitation which is an essential part of management.

• Tumor board involved
• Disability controlled
• Underwent planned surgery
• Adjuvant radiotherapy
• Aggressive rehabilitation

FINAL RESULTS

It has been a whole year since he was declared palliative. Such a dedicated and personalised approach towards patient management can change the outcomes by motivation and render a survival advantage.

CASE DESCRIPTION

A 60-year-old gentleman diagnosed with a synchronous distal sigmoid colon and lower rectal cancer associated with triple vessel disease presented to us in extreme distress with a 12 cm anal proliferative growth extending to gluteal regions because of which he was not able to sit and 20 kg recent weight loss. He had received neoadjuvant chemoradiotherapy almost a year back, and still radiologically he was a surgical candidate. He was deemed unfit outside and was in severe distress as he was not able to sit due to large growth and continuous bleeding.
Entire family was feeling helpless and mentally patient had given up.

Consultation and diagnosis
Prompt and accurate diagnosis made in-house

Tumour board
A multi-disciplinary team deliberated on action

Individualized care
Patient’s mental makeup taken into consideration
Counselling of entire family with patient as a centre give priority

Modular care
A suite of therapies that contribute to holistic healing.

WHAT WE DID

We conducted a multidisciplinary meeting with the cardiologist. After discussion, we decided to address the cardiac morbidity first which was a hindrance to our oncology treatment rather than treating oncology part first under high cardiac risk. We planned Angiography with angioplasty, and after a month, surgical resection with plastic reconstruction.

After angioplasty, the patient was on full anticoagulation medicine for which he required intermittent ICU admission due to bleeding from the anal growth. Finally, after one month, we optimised the patient and operated on dual antiplatelet agent and cardiac risk was taken care of. He underwent Extralevator Abdomino perineal resection with large gluteal muscle excision with plastic reconstruction (TRAM flap)

● Multi-disciplinary meeting
● Addressing Cardiac risk factor first
● Optimised patient’s condition & Psychosocial Counselling
● Performed planned surgery

FINAL RESULTS

He recovered well postoperatively and gained 10 kg in the next 6 months. He completed adjuvant chemotherapy. It has been 3 years since and he’s doing his agriculture work at his native place. This is a case of a personalised approach to the patient’s condition, which created a life-changing experience. Skill with the right attitude can give excellent outcomes.
Personalised teamwork can change outcomes.

CASE DESCRIPTION

A 78-year-old gentleman diagnosed with locally advanced cancer of the proximal stomach (cardia) with triple vessel disease came to our centre for opinion, as he was recommended surgery outside with high cardiac risk. He had taken 3 cycles of Neoadjuvant chemotherapy. He had taken multiple opinions outside which always pointed to the high cardiac risk. This case was discussed in our tumour board meeting with the cardiac surgeon.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

 Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

Applying a personalised approach, we planned to perform cardiac bypass first and then go for stomach cancer surgery within 3-4 weeks. We also counseled the patient for the same and he agreed to this. He underwent a Cardiac bypass and did postoperatively well due to our dedicated rehabilitation team. We operated on him after 4 weeks on blood thinners. We were successfully able to perform the Stomach cancer surgery eliminating cardiac risk (Radical Proximal Gastrectomy with D2 Lymphadenectomy surgery)

• Applied personalised approach
• Performed cardiac bypass first
• Underwent stomach surgery
• Decreased cardiac mortality risk
• Rehabilitation worked wonders

FINAL RESULTS

Postoperatively, we had some challenges with bleeding as he was on blood thinners, but the most critical thing was how we decreased the cardiac mortality risk by doing a bypass first. He has recovered and tolerated 2 major surgeries in a span of 4 weeks. It was only possible by a personalised multidisciplinary approach along with a rehabilitation team

At present he is doing well and leading a balanced life.

CASE DESCRIPTION

A 93-year-old lady diagnosed with sigmoid colon cancer locally advanced presented to us with decreased appetite and failure to thrive. Given her elderly age, her relatives were apprehensive about whether we should opt for surgery or let her live with cancer without giving surgical trouble. They had taken multiple opinions and were given mixed responses due to her age factor and limited mobility. Also, the patient was counselled for a diversion stoma for which she was not ready.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

When the case was referred to us for opinion, we planned a laparoscopic sigmoid colectomy as for her age she was fit and motivated. Age is just a number; our motto is optimising mental fitness first. Most important is to think in a retrospective manner, if you don’t opt for treatment what will happen. In her case, if she does not opt for surgery, she would have landed in emergency intestinal obstruction with high risk of mortality. So our decision was simple: to go ahead with surgery. As planned, we could successfully complete the entire surgery laparoscopically with no diversion stoma. She recovered well and was discharged on day 5 in a condition she was in before. Her diet included the consumption of 3 glasses of milk every day for the last 30 years and we continued the same postoperatively.

• Tumour board involved
• Laparoscopic surgery ( Minimal Invasive Surgery
• Personalised care
• NO Diversion stoma
• Managed age and mobility by personalised Rehabilitation team

FINAL RESULTS

Now, it has been more than 2 years and  she is doing well in her nineties with a good quality of life. Patient motivation is a key factor, which we took into consideration.

Important information: For the geriatric age group, just correct the problem and let them lead the life they are used to because that helps them to recover fast (the moment we stopped protein powder and started 3 glasses of milk she was walking with confidence because that is her staple diet)

CASE DESCRIPTION

A 23-year-old young boy presented to us in an extreme distress with bilateral tubes placed in the kidney (PCN) as patient was not able to pass urine on her own because of a large retroperitoneal mass  encasing the ureter, aorta, common iliac veins and left renal artery . He was in a condition of failure to thrive. On the CT scan, we could not see the branches of the aorta. He was put on neoadjuvant chemotherapy outside but the disease progressed and his mental will power started giving up. He visited multiple centres in India and also took opinions from Singapore. The response was that it could not be operated on and that there was a high chance he would die on the table.  Somehow, Google helped him reach us for one more opinion.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

The first thing that came to my mind: he is a young patient with a germ cell tumour (Mature Teratoma) that does not respond to chemotherapy, and he was struggling with his life not being able to eat and walk normally. Since it was a Germ cell tumour, we can always operate with good outcomes. I counseled him that we would perform surgery and assuaged his worries. We had a multidisciplinary meeting, and we planned our surgery with an Intensivist, vascular surgeon, and anaesthetist. The entire team was motivated. We could successfully remove the entire retroperitoneal tumour, which took more than 12 hours and required a massive blood transfusion. The universe seemed to be supporting us.

• Tumour board involved
• Counseling for the patient
• Germ cell tumour – Good Biology
• Arduous surgery performed
• Massive blood transfusion managed well by team

FINAL RESULTS

Postoperatively, he required an ICU stay for 4-5 days and he recovered well. All his PCN tubes were removed. He was able to eat and pass urine on his own. He gained 5 kg weight after 2 months. The first follow-up CT scan showed no disease recurrence at the operative site at 4 months and now it is almost a year he is doing well.

Learning: A personalised approach with an excellently skilled team and universe support can change outcomes.

CASE DESCRIPTION

A 55-year-old gentleman diagnosed with a carcinoma of pancreas head with obstructive jaundice, presented to us in extreme distress of pain and not able to eat. He was an operable case but due to high bilirubin and low albumin, he was recommended preoperative ERCP with biliary stenting. He was unfortunate to develop post-stenting pancreatitis. He was recommended conservative management and nutritional optimisation. When he was recommended for surgery after 3 weeks, he developed one more attack of pancreatitis. He had multiple episodes of pancreatitis and by now the patient had lost hope of recovery as surgery was a very high risk.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

We discussed this in our joint clinic and it was a tough decision for me and my team

,as we were aware of 70 percent mortality in severe pancreatitis patients planned for Whipple surgery. We had to decide as nothing was helping him. We optimised him nutritionally and planned for surgery with high operative risk. During Surgery, we saw that it was an extremely challenging case as the pancreas had undergone necrosis. The only thing running through my mind was, if I backed out, what were the consequences, and I realised that this was the only chance to take out the tumour. I continued and finally, I was able to perform the surgery with our excellent team. It took 12 hours to complete it. He required a prolonged ICU stay and aggressive physiotherapy rehabilitation as the patient was not motivated. After 20 days of good rehabilitation, he recovered.

• Optimised patient nutritionally
• Managed pancreatic necrosis & Whipple surgery
• Arduous surgery performed
• Aggressive physiotherapy and rehab

FINAL RESULTS

Postoperatively, he had a grade B leak which was managed conservatively. He is doing well now and his final histopathology report came out as Neuroendocrine tumour (a good variety of tumour), which was the icing on the cake. Neuroendocrine tumors are a rare variety but very good biology. Retrospectively thinking, if I would have backed out because of the difficulty, he would have been devoid of the curative surgery.

Note: Whipple surgery in patients with severe pancreatitis is a very big challenge. A personalised approach helps you to make the right decisions. According to the literature, we should not operate on such patients for 8-12 weeks. The most important thing is that every patient is different and has a different mindset which needs to be considered while making the decision.

CASE DESCRIPTION

A 40-year-old lady diagnosed with locally advanced cancer of the ovary. The challenge was her CA 125 was 9,600 (which is extremely high) with gross ascites.

Very rarely we see such high CA 125

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

She required high motivation and was started on neoadjuvant chemotherapy. After 3 cycles her CA 125 level remained the same. After discussion, we added Bevacizumab and after 2 doses, her CA 125 level started decreasing. She developed dengue after the 2nd dose of bevacizumab and therefore, a low platelet count. Since she had taken chemotherapy, she took one month to recover from dengue and we could not continue the chemotherapy. Her relatives were very apprehensive. We counseled them and after 2 months we prepared her for surgery (Cytoreductive surgery with HIPEC). Her CA 125 levels were on a reducing trend but still high.

She underwent Cytoreductive surgery. She had extensive small bowel mesenteric disease which we could remove entirely and a 90-minute chemotherapy was given during surgery which she tolerated. The surgery took 10-12 hours.

• Chemotherapy administered
• Dengue managed
• Counseled patient and family
• Underwent planned surgery with HIPEC
• Advanced disease cured

FINAL RESULTS

We could discharge the patient on day 6. She completed adjuvant chemotherapy. We did BRCA testing and she came positive and now she is on maintenance Olaparib. Now, it has been over one year,  her CA 125 is normal and she is doing well.

Learning: Challenges will be there but a personalised approach with continuous joint clinic discussion and persistent patient counseling and motivation can change the tide in your favour.

CASE DESCRIPTION

A 69-year-old diagnosed with recurrent retroperitoneal sarcoma. The patient underwent multiple surgeries outside with no response to chemotherapy over the last 18 months . With gross disease recurrence and with failure to thrive, she was distressed. The only way to comfort her was to perform one more surgery with a high chance of recurrence. The challenge for surgery was that she was very weak.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

After discussion, we planned to operate after optimization only to give a good quality of life as a human being. We could successfully operate on her with a 12 kg retroperitoneal mass.

• Tumour board involved
• Optimised patient condition
• Quality of life given
• Successful surgery

FINAL RESULTS

Postoperatively, she recovered well. She had a good 4-6 month postoperative care with mobility and eating well. After 6 months, she had a recurrence and she succumbed. Those 6 months of relief we provided her helped relatives prepare themself for accepting the inevitable

Learning:  Acceptance in life is a very important factor for completion. Relatives had a sense of satisfaction that they did whatever best they could do. A personalised approach takes into consideration science, and most importantly, humanity. Blending spirituality with science can give you satisfaction and peace. At the same time, it should be acceptable and affordable.

CASE DESCRIPTION

A 45-year-old lady was diagnosed with carcinoma Endometrium and treated outside 2 years back with surgery followed by 6 cycles of adjuvant chemotherapy. On follow-up, she developed recurrence within one year with liver metastasis. Considering she had metastatic disease, she was declared palliative. So, she was considered for palliative chemotherapy. On restaging, FDG PET CT showed only a single large liver segment VIII lesion. She came to us for a second opinion.

Consultation and diagnosis

Prompt and accurate diagnosis made in-house

Tumour board

A multi-disciplinary team deliberated on action

Individualized care

Patient’s mental makeup taken into consideration

Modular care

A suite of therapies that contribute to holistic healing

WHAT WE DID

The case was discussed in the Tumour board and a decision was made to revisit the histology because such an early recurrence with liver only site of the disease on chemotherapy is a little rare. Outside, the biopsy showed poorly differentiated carcinoma and IHC was not done before declaring her palliative. After revisiting the biopsy, it showed up as neuroendocrine carcinoma which is a different entity in itself. So we started chemotherapy relevant to the histology and she showed an excellent response. After 6 cycles, we planned to observe her for  3 months to check the biology. On restaging, the FDG PET CT scan showed liver-limited disease with excellent response. After the tumour board discussion, we planned for a Right hepatectomy. Her FLR was 40 percent. She underwent Right hepatectomy and did well after surgery. She was discharged on POD4. To our surprise, the liver histology showed up as neuroendocrine but diaphragmatic nodes as adenocarcinoma from ca Endometrium positive for hormone receptors.

So, liver lesions were probably primary neuroendocrine carcinoma, which is very rare. We started her on hormonal therapy based on nodal disease histology.

• Involved Tumour Board
• Chemotherapy administered
• Underwent surgery
• Personalised approach
• Palliative turned curative

FINAL RESULTS

Now, it has been  18 months Post Op. The recent FDGPETCT showed no disease, the patient is extremely fit and working with a good quality of life.

Learning: Best-thinking brains with personalised approaches can change the outcome. A patient who was declared palliative is now curative and disease-free.