Assessment of the Association between Clinical Examination and Investigations with Outcome in Cases of Abdominal Malignancy

Introduction: Abdominal malignancy is a serious problem in the western world which is presently rising in India due to change in lifestyle. The etiopathogenesis are hereditary, environmental and lifestyle factors. The signs and symptoms vary depending upon the type and stage of cancer. Routine investigations, tumor markers, radiology, endoscopy and biopsy examine patients. There have been advances in chemotherapy, radiotherapy, and palliation but still surgery is curative. Methods: This is a prospective observational study including all cases of abdominal malignancy presenting to Surgery OPD. The sample size is 46 patients. Results: Mean age of presentation is 54.63 years. Preoperative abnormal parameters such as CEA, CA 19-9, preoperative biopsy, lymph nodal metastasis on CT and liver metastasis on CT were correlated with outcome which were found to be significant. Operative findings such as site, area, spread outside serosa, lymph nodal metastasis, and liver metastasis were correlated with same in the radio-pathological findings and were found to be significant. Outcome was assessed. Reasons for delay in presentation, diagnosis and treatment were assessed. Conclusion: Maximum number of patients were in the age group of 41-60 years. There was a definite difference in outcome with reference to preoperative abnormal parameters. There was comparative variation of operative and radio-pathological findings. Study subjects death were due Original Research Article Rashmi and Jajoo; JPRI, 33(64B): 433-446, 2021; Article no.JPRI.71283 434 to malignancy as most of them presented to the hospital at advanced stages of malignancy and others dropped out of chemotherapy or radiotherapy and those who took proper treatment had good outcome.


INTRODUCTION
Abdominal malignancy is a serious problem in the western world which is presently rising in India due to change in lifestyle. It is a general term that encompasses cancers of various organs in the area between the diaphragm and the groin, that is, stomach, liver, gallbladder, pancreas, small intestine, large intestine (caecum, colon, rectum and anal canal) and urological system [1].
As per the GLOBOCAN 2018 data, incidence wise, colorectal cancer, gastric cancer and liver cancer ranks third, fifth and sixth, respectively after Lung, female breast cancer and prostate cancer. Gall bladder, pancreas and small intestine cancers are less common [1].
The signs and symptoms of abdominal malignancy vary depending upon the type and stage of cancer. The patients may be asymptomatic in the initial stages of the cancer, but with progression, may experience symptoms such as dyspepsia, abdominal or mid-back pain, nausea, vomiting, change in bowel habits, loss of appetite, significant weight loss, jaundice, itchy skin fatigue and fever. The signs in the patients may be anemia, obstructive jaundice, hematemesis and rectal bleeding [2,3,5].
Abdominal clinical examination gives clues for the diagnosis of malignancy [6]. The abdominal examination is done as inspection, palpation, percussion, and auscultation [7].
After this the routine investigations (CBC, LFT, KFT) are done. Patients are further investigated by radiology, biopsy, tumor markers and endoscopy. Among the imaging methods, Transabdominal ultrasonography (USG) is a noninvasive and first line investigation [8].
CT scan is the investigation of choice preoperatively for diagnosing abdominal malignancies. It is less expensive than the other imaging modalities such as MRI and less invasive than endoscopic procedures [9].
Upper gastrointestinal endoscopies are considered as the gold standard for the management of gastric cancers. It is useful in screening symptomatic patients [10]. Colonoscopy has become increasingly popular for screening [11].
The pathology reporting can be supported by tumor markers such as carcinoembryonic antigen (CEA) and cancer-related antigen  used in abdominal malignancies. These tumour markers are used in staging and follow-up of patients [12].
The diagnosis and management approach is dependent upon a good relation between the clinical examination and investigations [13]. During the last decades though there have been advances in chemotherapy, radiotherapy and palliation; surgery is the curative one [14].
Abdominal malignancies carry a high fatality rate because of delayed presentation. Colorectal cancer, gastric cancer and liver cancer ranks 2 nd , 3 rd and 4 th leading causes of mortality related to cancers [1].

Rationale:
This study was done to study the clinical and epidemiological factors which will give information regarding early symptoms & signs helping in early diagnosis. To find preoperative abnormal parameters affecting the ultimate outcome. To correlate the radiological evaluation and not operative findings to decide the appropriate treatment. To analyze and evaluate cause of delay.

Objectives:
 To evaluate clinical and epidemiological parameters in cases of abdominal malignancy.
 To relate preoperative abnormal parameters with ultimate outcome in cases of abdominal malignancy.  To relate actual operative findings with radiopathological findings.  To assess the outcome of treatment in abdominal malignancy.  To determine cause of delay in initiating specific therapeutic procedures.

MATERIALS AND METHODS
The current study was conducted in the Department of surgery at rural tertiary health care center -Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, India. Study design is prospective observational study. Study population is those attending Department of Surgery OPD and admitted to AVBRH hospital. The duration of study is 2 years (From September 2018 to August 2020).

Inclusion criteria:
All the patients coming to AVBRH for the treatment of abdominal malignancies.

Methodology:
This was a prospective observational study carried out from September 2018 to August 2020. This study was conducted after obtaining the written informed consent of the patients. All the patients who were diagnosed as a case of abdominal malignancy were included in the study.
Detailed history of the patient was taken including age and sex and chief complaints. A standardized sequence of clinical examination was chosen inspection, palpation, percussion and auscultation. Each step of abdominal examination carries its importance in ruling out a plethora of differentials.
After detailed history and clinical examination, patients were subjected to routine blood investigations, tumour markers, Ultrasonography, Endoscopy/colonoscopy with guided biopsy and computed tomography.
After diagnosis of abdominal malignancy tumour was either surgically operated or palliative treatment that includes palliative surgery, palliative chemotherapy and palliative radiotherapy were given. These findings were noted and were followed up for a period of 6 months.

OBSERVATIONS AND RESULTS
In the present study it was observed that mean age of presentation was 54.63 ± 10.8years, Both median and mode were 55 years. Out of 46 patients, there were 30 patients (maximum) in the 41-60 years age patient. The age range was between 35 -87 years (Graph 1).

Association of Operative and Radiological Findings:
Kim et al conducted a study of 95 cases of gastric cancer. Intraoperatively 45 out of 86 cases had lymph node metastasis only 12 were identified correctly and 5 were false positive on CT. Intraoperatively 10 patients had enlarged celiac lymph nodes and 2 patients were identified correctly & 3 patients were false positives. CT has underdiagnosed lymph node metastasis. Intraoperatively 4 patients showed liver metastsis, 2 showed mesocolon involvement and 11 showed peritoneal metastasis and none, 2 patients and none were identified on CT respectively. CT has underdiagnosed liver metastasis and metastasis to other structures [37]. This study disagreed with Kim et al because of small number of cases are operated. Sensitivity of CT in my study is 100% in detecting lymph node metastasis and 50% in detecting liver metastasis and 100% in detecting metastasis to other structures. Vidya Jha et al in their study of 20 patients of gall bladder cancer identified intraoperatively, 11 (55%) patients showed thickening of gallbladder wall, 2 (10%) patients showed mucosal ulceration, 7(35%) patients did not show any features suggestive of malignancy [38]. Agreement of this study with Vidya Jha et al cannot be identical as only small number of cases are operated.
Elbarbary et al in their study of 44 colorectal malignancy patients observed that on CT scan lymph node metastasis in 31 (70%) patients were correctly identified and 13 (30%) were incorrectly assessed. Sensitivity of CT in detecting lymph node metastasis was 69% and specificity was 76% [41]. They also observed that 41 (93%) patients showed liver metastasis, CT scans evaluated 41 scans (93%) correctly. Sensitivity of preoperative CT for liver metastases was 89% and specificity was 96% [41]. They also observed that Lung metastasis were found in 2 patients which were identified correctly on CT. Sensitivity of CT was 100% [39]. This study is consistent with Elbabary et al in terms of lymph node metastasis with a sensitivity of 78% and specificity of 71%. Sensitivity of CT for detecting liver metastasis is 82% and specificity is 56%. Sensitivity of CT in detecting metastasis to other structures is 100% . Singla et al in their study of 31 patients of colorectal cancer, Sensitivity of CT was 83.3% and specificity of CT was 92%, for T1 and T2 lesions. Sensitivity of CT was 88.2% and specificity of CT was 93.8%, for T3 lesions. Sensitivity of CT was 100% and specificity of CT was 100% for T4 lesions [40]. This study is in agreement with Singla et al in terms of sensitivity of spread outside serosa. Sensitivity of CT for detecting lymph node metastasis 94% and specificity is 75%.

Association of Operative and Pathological Findings:
Lee et al in their study of 67 study patients of gastric cancer, 55 patients underwent surgery. Intraoperatively in all 55 lymph nodes were enlarged and removed. On histopathologic examination, 20 (36.4%) had lymph nodal metastasis. Specifiicty is 36% [42]. On surgical and histopathologic examination, spread outside serosa was seen in 21(38.2%) patients. Sensitivity is 100%. On surgical and histopathologic examination, 8 patients had solid organ metastasis and 18 patients had peritoneal metastasis. 5 patients had metastasis in both [41]. This study is not similar with Lee et al because of smaller number of cases operated gastric cancers and correlating in terms of spread outside serosa and solid organ metastasis.
Jha et al in their study of 20 patients of gall bladder carcinoma observed that intraoperatively there was thickening of gallbladder wall in 11(55%) patients and mucosal ulceration in 2(10%) patients. 7(35%) patients did not show any features suggestive of malignancy. 14 patients had gall stones. On histopathological examination, all patients had features of adenocarcinoma. Lymphovascular invasion was observed in 14 patients. Perineural invasion was seen in 2 patients. Tumour cells were seen infiltrating the lamina propria in 3 patients (pT1b), muscularis propria in 15 patients (pT1b) and serosa in 2 patients (pT2) [38].
Singla et al in their study of 31 colorectal malignancy patients observed that spread outside serosa was properly diagnosed in 23 cases out of 24 cases [40]. Bembenak et al in their study of 268 colorectal malignancy patients 82 had lymph nodal metastasis intraoperatively 44 of these were identified correctly on histopathology [42]

Reasons for Delay in Presentation, Diagnosis and Treatment:
Vivek Tiwari et al in their study concluded that the patient's factors are the major causes of delay as compared to hospital factors. Common reasons for patient delay were lack of awareness about signs and symptoms of malignancy, consulting unqualified or local practitioners or taking no consultation, use of alternative medications, poor socio-economic conditions and lack of a proper referral to tertiary health care centre [46]. A K Dwivedi et al in their study observed the causes for delay in presentation 54.6% patients due to lack of awareness, 12.4% patients due to Economic problems, 3.5% patients due to Fear of cancer, 4.5% patients distance problems, 8.7% due to family problems, 30% of the patients made more than two medical contacts for confirming the diagnosis [47]. Hospital factors as cause of delay include in 27.5% patients inappropriate diagnosis, 50% patients were advised symptomatic treatment before establishment of diagnosis, 7% of the patients were assured that the disease is not a matter of serious concern, 60% of the patients contacted small clinics/primary health centres [48]. Mohammed et al in their study observed the diagnosis of malignancy was delayed at different levels. The patients were not able to identify symptoms of malignancy. Primary care physicians fail to identify patients with suspicious malignancy symptoms. They may not investigate them appropriately or refer them to a tertiary health care centre on time. Patients with suspicious malignancy may not reach the secondary care on time, or they may be reach the wrong specialty [49]. This study is in agreement with Vivek Tiwari et al, A K Dwivedi et al and Mohammed et al. [50][51][52] Few other related studies were reported [53][54][55][56][57].

CONCLUSION
Abdominal malignancies are a common problem in the western world which is on a rise in India due to changes in lifestyle. This study was conducted in AVBRH, a rural based hospital which caters to rural population where priority of health against living is less, infrastructure support is compromised and thus ultimate outcome is associated with high financial burden and poor outcome. The study was used to study the accuracy of each of the investigation in predicting the outcome and delay due to patient and hospital factors.
Mean age of presentation was 54.63 ± 10.8 years with maximum number of patients in the age group of 41-60 years. Considering the preoperative abnormal parameters, elevated CEA and CA19-9 levels are associated with poor outcome as compare to those with normal levels. In case of preoperative biopsy findings undifferentiated cancers have a poor outcome as compared to well differentiated cancers. If lymph nodal or liver metastasis are present on CT at the time of diagnosis it is associated with poor outcome. Thus, there is a definite difference in outcome with reference to preoperative abnormal parameters.
Relating the operative and radiological findings: there is significant change in terms of diagnosis of site identified by both, but length identified by both is not significant and different. Lymph nodal metastasis, spread outside serosa, ascites, liver metastasis and metastasis to other structures in both are comparative.
Relating the operative and post-operative histopathological findings: there is significant change in terms of site identified by both findings, but length, breadth, proximal margin and distal margin identified by both is not significant. Lymph nodal metastasis, spread outside serosa, and metastasis to other structures in both are significant.
At 1 year follow up 55% of the study subjects died due to malignancy as most of them presented to the hospital at advanced stages of malignancy and others dropped out of chemotherapy or radiotherapy and 37% had good outcome as they took proper treatment. Most of the patients presented in advanced stages to the hospital because of taking local treatment (41%) or moving from one doctor to other. This is because there is lack of awareness (17%), belief in herbal (15%) and ayurvedic (9%) treatment, poor financial resources (12%), and fear for surgery (6%). The proper treatment is delayed or denied leading to poor overall outcome.
Delay in diagnosis is again mainly due to poor compliance of patient being irregular for investigations due to personal reasons and other reasons are non-availability of particular doctor, repeated negative biopsy reports. Delay in treatment is mainly due to delay in diagnosis, as biopsies were inadequate tissue, delay in insurance policy, non-availability of blood or patient's personal reason. Dropout from chemotherapy was mainly due to side effects and financial reasons. Dropout from radiotherapy is due to travelling issues as radiotherapy was not available at our setup.

CONSENT
This study was conducted after obtaining the written informed consent of the patients.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).