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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 123-124

Authors' reply to Krishnamurthy et al., Gupta et al., Mondal, and Muthusamy


1 Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
2 Department of Biostatistics, Malabar Cancer Centre, Thalassery, Kerala, India

Date of Submission26-Jan-2020
Date of Acceptance26-Jan-2020
Date of Web Publication24-Feb-2020

Correspondence Address:
Nizamudheen M Pareekutty
Department of Surgical Oncology, Malabar Cancer Centre, Thalassery - 670 103, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_42_20

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How to cite this article:
Pareekutty NM, Kattepur AK, Malodan R. Authors' reply to Krishnamurthy et al., Gupta et al., Mondal, and Muthusamy. Cancer Res Stat Treat 2020;3:123-4

How to cite this URL:
Pareekutty NM, Kattepur AK, Malodan R. Authors' reply to Krishnamurthy et al., Gupta et al., Mondal, and Muthusamy. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Mar 30];3:123-4. Available from: http://www.crstonline.com/text.asp?2020/3/1/123/279115



We are grateful to Krishnamurthy and Karthik,[1] Gupta and Gulia,[2] Mondal,[3] and Muthusamy[4] for their valuable comments on our articles published on the topics of unplanned excision of soft-tissue sarcoma and limb-salvage surgery for osteosarcoma.[5],[6] We also thank Dr. Akshay Tiwari for the combined editorial on the articles.[7]

Krishnamurthy and Karthik[1] have rightly pointed out that none of the factors which we thought should have affected survival, i.e., tumor size, grade, and histology had statistically significant differences between the two groups. We had noticed that there was a strong tendency for higher tumor size, tumor volume, high-grade tumors, and unfavorable histology in the group of patients who underwent planned excision in a cancer center as compared to those who underwent unplanned excision outside (uP). We believe that statistical significance would have been attained in a larger sample. We also agree with the authors that education among surgeons is important to avoid unplanned excision and subsequent psychological trauma of patients.

Although 12 patients had lung metastases, only four patients had resectable pulmonary nodules prompting us to perform metastatectomy in them. Further, three of these patients in the unplanned group remained alive without disease till the end of the study. As the numbers are small, elaborate discussion is difficult. We also agree with the authors that there is a huge unmet need for second-line treatment of osteosarcoma and soft-tissue sarcoma.[8] In our series, none of the patients with osteosarcoma received second-line chemotherapy.

As pointed out by Gupta and Gulia,[2] in three patients, biological material (free fibula graft) was used for reconstruction. It was done in children with tumor involving the humerus. Because only eight patients in our series had subsequent lung metastatectomy, a comparison of individual outcomes with number of lung metastasis would have been too thinned out in numbers. We acknowledge the error that happened when drafting the materials and methods section of the article regarding the MSTS score. We have confirmed that the assessment has happened properly. We converted the scores into percentage values in the results for better comparison. The 18 patients who had defaulted were excluded from our analysis because the time frame at which they presented to us was too long and they did not receive protocol treatment. We agree with the authors that in a resource-limited nation like India, less costly investigations such as chest radiograph and ultrasound may be the investigations of choice for follow-up of these patients instead of computed tomography (CT) scan without compromising on survival as shown by Puri et al.[9] At our institute, the follow-up schedule consists of 6-monthly X-ray of the chest, with CT scans of the thorax annually as per international guidelines. Better outcomes within 12 weeks of re-resection are difficult to capture from retrospective case histories as more often than not, details about the place of surgery, who performed the surgery, the preoperative diagnosis, etc., are not written. We fully agree that these important points can add more weight to the type of unplanned excision being performed.

We agree with Mondal[3] that there was a typographical error in the total number of cases with local recurrence which should be read as 9 instead of 3. The total number of 69 cases represents the number of patients who underwent surgery in the center. The differences in negative resection margin may have been negated using adjuvant radiotherapy.

As mentioned by Muthusamy,[4] one of the factors responsible for inferior survival for osteosarcoma in Indian patients is larger tumor size and delayed referral.[10] In another Indian series, 25% of patients underwent amputation. In our experience, only 3 (6.81%) patients required upfront amputation during the study. The overall survival was superior for non-metastatic patients and is comparable to Western data. This difference probably resulted from regional differences in socioeducational level of the population and awareness about the illness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krishnamurthy A, Karthik V. Addressing the unmet need of improving survival outcomes of bone and soft tissue tumors. Cancer Res Stat Treat 2020;3:119-20.  Back to cited text no. 1
  [Full text]  
2.
Gupta S, Gulia A. Raising the bar – Sarcoma management in India. Cancer Res Stat Treat 2020;3:120-1.  Back to cited text no. 2
  [Full text]  
3.
Mondal A. Whoops! – Is it too early to judge? Cancer Res Stat Treat 2020;3:121-2.  Back to cited text no. 3
  [Full text]  
4.
Muthusamy S. Limb salvage surgery in osteosarcoma: Comment on Indian perspective. Cancer Res Stat Treat 2020;3:122-3.  Back to cited text no. 4
  [Full text]  
5.
Pareekutty NM, Kattepur AK, Alapatt JJ, Satheesan B. Unplanned excision in soft-tissue sarcomas – Is it the unkindest cut of all? Cancer Res Stat Treat 2019;2:152-7.  Back to cited text no. 5
  [Full text]  
6.
Ankalkoti B, Pareekutty NM, Kattepur AK, Kumbakara R, Vazhayil R, Balasubramanian S. Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center. Cancer Res Stat Treat 2019;2:145-51.  Back to cited text no. 6
  [Full text]  
7.
Tiwari A. Management of bone and soft-tissue sarcomas: From state of practice to state of art. Cancer Res Stat Treat 2019;2:215-6.  Back to cited text no. 7
  [Full text]  
8.
Turkar S. Current treatment landscape and emerging management options for extremity sarcoma. Cancer Res Stat Treat 2018;1:121-38.  Back to cited text no. 8
  [Full text]  
9.
Puri A, Ranganathan P, Gulia A, Crasto S, Hawaldar R, Badwe RA. Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb? Updated results of the randomized TOSS study. Bone Joint J 2018;100-B:262-8.  Back to cited text no. 9
    
10.
Puri A, Byregowda S, Gulia A, Crasto S, Chinaswamy G. A study of 853 high grade osteosarcomas from a single institution-are outcomes in Indian patients different? J Surg Oncol 2018;117:299-306.  Back to cited text no. 10
    




 

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