Prostate cancer presentation and management in the Middle East.

BACKGROUND: Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region. METHODS: A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables. RESULTS: A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment. CONCLUSION: Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

Moving Experience from North America to Developing Country to Approach a Desired Level of Quality Assurance in Head and Neck Radiation Therapy.

Evidence is lacking correlation between head and neck (HN) radiation oncology fellowship training and quality assurance (QA) round decision for plan modifications. This study was conducted to identify the association between training and changes in QA decisions. From 2007 to 2018, data on HN cancer cases presented at departmental QA rounds were prospectively collected. Then, we retrospectively analyzed the collected data to determine the impact of fellowship training on QA decisions. Cases were divided into pre-fellowship group (January 2007-September 2014) and post-fellowship group (October 2014-December 2018). Multivariable analysis (MVA) evaluated variables that could be associated with decreased frequencies of QA modification rates. From 2007 to 2018, 1266 HN cancer patients were identified; 728 patients were in the pre-fellowship group and 538 patients in the post-fellowship group. On MVA, fellowship training transformed QA decisions from more to less modifications (modified vs. approved; OR, 0.135; 95% CI, 0.076-0.240; p = 0.0001), increased approval rate for advanced T and N categories (T3-4 vs. T0-T2; OR, 0.798; 95% CI, 1.892-4.929; p = 0.0001 and N2-3 vs. N0-1; OR, 0.865; 95% CI, 1.454-3.423; p = 0.0002). By type of modification, fellowship training demonstrated a statistically significant reduction in rates of several types of modification that include target volume definition, target volume delineation, and dose (all p < 0.05). Our study determines the impact of the HN radiation oncology fellowship on decreased QA modification rates.

Factors influencing the use of adaptive radiation therapy in vulvar carcinoma.

AIM: We aim to evaluate the variables affecting the frequency of adaptive radiotherapy (ART) in vulvar cancer. BACKGROUND: ART may be needed throughout a definitive RT course for vulvar carcinoma due to changes in patient's anatomy and tumor response. MATERIALS AND METHODS: Charts of patients charts who had been treated with definitive concurrent chemo-radiotherapy for vulvar carcinoma, between January 2015 and December 2019 were inquired. Radiation therapy was delivered using intensity modulated radiotherapy (IMRT) with daily image-guided radiotherapy (IGRT). ART was defined as re-simulation and re-planning based on deformation in the irradiated volume by more than 1 cm. Univariate analysis was conducted to study the impact of patient's demographics as well as tumor characteristics on the frequency of ART. RESULTS: 22 patients were eligible for analysis. Median age at diagnosis was 55 years (range 43-82). Radiotherapy dose was 60-66 Gy over 30-35 fractions (fx). Median primary tumor volume was 30cc (9-140). Median Body Mass Index (BMI) was 32 (range 21-40). Thirteen out of 22 patients (59%) required ART, with median timing at 25 fx (19-31). On univariate analysis, larger primary tumor volume (> = 30cc) was associated significantly with increased frequency of ART (p value = 0.0005). There was no significant impact of ART on the frequency with respect to patient's age, BMI, tumor stage, grade and location. CONCLUSION: Changes in radiation target volume are common among vulvar carcinoma patients who are treated with definitive radiotherapy, especially large primary tumors. This review highlights the importance of ART for patients with vulvar carcinoma treated with definitive radiotherapy.

The impact of local control timing in Ewing sarcoma.

AIM: To assess the impact of delay in local control on survival outcomes of Ewing sarcoma (ES) patients. BACKGROUND: The cornerstone of therapy of localized ES includes chemotherapy and local control with surgery or radiotherapy. We sought to assess the impact of delay (>15 weeks) in timing of local control on survival outcomes of ES patients. METHODS: Data of consecutive patients with primary non-metastatic ES of the extremities, treated at a single institution were collected. The impact of delay of timing for local control, demographics, and disease characteristics on overall survival (OS) was analyzed. RESULTS: A total of 43 patients with ES of the extremity were included. All patients received neoadjuvant chemotherapy. Local control was by surgery in 36 patients and definitive radiation in 7. A total of 16 patients had delay in local control. At a median follow of up of 48 months, patients with delay in local control had significantly inferior OS compared to those with optimal local control timing (5-year OS 56% vs. 80%, respectively, p = 0.044). Other factors that predicted inferior OS included definitive radiation as opposed to definitive surgery (5-year OS 25% vs. 79%, respectively, p = 0.041) and tumor necrosis <90% as opposed to ≥90% (5-year OS 55% vs. 90%, respectively, p = 0.01). CONCLUSION: Delay in definitive therapy, local control with radiation as opposed to surgery and poor post-chemotherapy tumor necrosis predict inferior OS in ES. Adopting strategies to minimize delay in local control could improve survival outcomes.

Adaptive radiotherapy in patients receiving neoadjuvant radiation for soft tissue sarcoma.

AIM: The aim of this study is to evaluate tumor volume changes during preoperative radiotherapy and to assess the role of adaptive radiation. BACKGROUND: Contemporary neoadjuvant radiotherapy utilizes image guidance for precise treatment delivery. Moreover, it may depict changes in tumor size and shape. MATERIALS AND METHODS: Between 2016 and 2018, 23 patients aged ≥18 years with soft tissue sarcoma were treated with neoadjuvant radiation followed by surgical resection. The tumor volumes (cc) were measured using the Pinnacle planning system prior to starting radiotherapy and during treatment, the changes in volume and absolute differences were estimated. Moreover, patient's position on the machine was evaluated to assess setup offsets. The triggers for plan adaptation were >1 cm expansion or unacceptable setup offsets. RESULTS: The mean tumors volume at presentation was 810 cc (range, 55-4000). At last cone beam CT the tumor volume had changed in 14 patients (61%); it was stable in nine patients (39%). Disease regression was documented in eight patients (35%), with median shrinkage of -20.5% (range, -2 to -29%), while tumor progression was observed in six cases (26%), the median change was 12.5% (range, +10 to +25%).Adaptive radiation was required in four patients (17%). For the remaining 19 cases (83%), the dose distribution was adequate to cover target volumes. CONCLUSIONS: Change in soft tissue sarcoma volume during radiation is not uncommon. Image guidance should be used to reduce setup errors and to detect differences in tumor volume. Image guidance and adaptive radiation are paramount to ensure optimal radiation delivery.

Induction Methotrexate, Cisplatin, and 5-Fluorouracil Versus Cisplatin and 5-Fluorouracil Followed by Radiotherapy in Pediatric Nasopharyngeal Carcinoma: A Retrospective Analysis in a Tertiary Cancer Center.

PURPOSE: The purpose of this study is to compare treatment outcomes of methotrexate, cisplatin, and 5-fluorouracil (MPF) or cisplatin and 5-fluorouracil (PF) in pediatric NPC patients treated with sequential chemoradiotherapy. PATIENTS AND METHODS: A total of 25 patients aged 18 years or below with stage II-IV NPC treated with IC using PF (n=16) or MPF (n=9) followed by radiotherapy between 2003 and 2009 were retrospectively reviewed. Radiotherapy dose was 61.2 to 66.6 Gy to the gross disease. Age, stage, radiation dose, and chemotherapy regimen were tested as prognostic factors for event-free survival (EFS) and overall survival (OS) on univariate and multivariate analyses. RESULTS: The median age at diagnosis was 13.3 years. All patients completed planned chemotherapy. All patients who received MPF achieved PR whereas 15 patients (93.8%) who received PF achieved PR (P=1). There were no differences in EFS (68.75% vs. 66.67%; P=0.84) and OS (81.25% vs. 66.67%; P=0.39) at 5 years between PF and MPF, respectively. On multivariate analysis, only tumor stage (IV vs. II-III) predicted worse OS (hazard ratio, 10.3; 95% confidence interval, 1.197-88.974) but not EFS (hazard ratio, 4.805; 95% confidence interval, 0.95-24.336). Distant metastases was the predominant site of failure, seen in 5 patients (20%). CONCLUSIONS: Omission of methotrexate from the induction chemotherapy regimen did not affect treatment outcome.

Review of management and morbidity of pediatric craniopharyngioma patients in a low-middle-income country: a 12-year experience.

BACKGROUND: Management of craniopharyngioma in children is challenging, and their quality of life can be significantly affected. Series describing this from low-middle income countries (LMIC) are few. PATIENTS AND METHODS: The study provides a retrospective chart review of pediatric patients <18 years old, diagnosed with craniopharyngioma between 2003 and 2014, and treated at King Hussein Cancer Center, Jordan. RESULTS: Twenty-four patients (12 males) were identified. Median age at diagnosis was 7.4 years (0.9-16.4 years). Commonest symptoms were visual impairment and headache (71%). Review of seventeen preoperative MRIs showed hypothalamic involvement in 88% and hydrocephalus in 76%. Thirteen patients (54%) had multiple surgical interventions. Five patients (21%) had initial gross total resection. Eleven patients (46%) received radiotherapy and six (25%) intra-cystic interferon. Five years' survival was 87 ± 7% with a median follow-up of 4.5 years (0.3-12.3 years). Four patients (17%) died; one after post-operative cerebral infarction and three secondary to hypothalamic damage. At their last evaluation, all but one patient required multiple hormonal supplements. Ten patients (42%) had best eye visual acuity (VA) >20/40, and four (16%) were legally blind. Eleven patients (46%) were overweight/obese; one had gastric bypass surgery. Seven patients had hyperlipidemia, and eight developed fatty liver infiltration. Eleven patients (65%) were attending schools and one at college. Nine of the living patients (53%) expressed difficulty to engage in the community. CONCLUSIONS: Management of pediatric craniopharyngioma is particularly complex and demanding in LMIC. Multidisciplinary care is integral to optimize the care and minimize the morbidities. A management outline for LMIC is proposed.

Inferior vena cava involvement in children with Wilms tumor.

OBJECTIVES: Retrospective review of children with WT thrombus involving the IVC. METHODS: We reviewed the charts of 123 patients with WT diagnosed between January 2006 and December 2015. Patients with caval tumor thrombus were identified, demographic data, radiological images, extent of thrombus, chemo- and radiotherapy, surgical approach, pathology reports and outcomes were analyzed. RESULTS: IVC involvement was identified in 11 patients (9%). Left-sided tumors were more common (55%). Sensitivity of CT scan in thrombus identification was 64%. Neoadjuvant chemotherapy was the primary mode of treatment with 19% reduction of primary tumor size, thrombus resolution in four and regression in six patients. No thrombus progression was observed. Delayed surgical treatment was either nephro-ureterectomy (nine patients) or partial nephrectomy in patients with bilateral WT (two patients). During surgery, thrombectomy and intimal stripping achieved local control in patients with persistent caval tumor. Cardiopulmonary bypass was not needed in patients with initial atrial involvement (five patients). Despite adherence and invasion of tumor thrombus to IVC wall, only one patient required segmental vein resection. All patients eventually achieved CR, none had local relapse. One patient had lung relapse treated to complete remission. The 3-year EFS is 85.7 ± 13.2% and the 3-year OS is 100%. CONCLUSION: IVC tumor thrombus in patients with WT was managed successfully using preoperative chemotherapy followed by surgery with minimal aggressive approach. Luminal thrombus removal and intimal stripping supplanted by local radio boost when indicated seem to be adequate tools for local control with documented good overall outcomes.

Comprehensive Analysis of Metastatic Prostate Cancer: Real-World Data From the Middle East.

PURPOSE: Metastatic prostate cancer (Pca) is a complex disease with diverse clinical characteristics and outcomes across the geographical distribution. Herein, we present a series of patients from the Middle East, aiming at identifying disease outcomes and prognostic factors specific to this regional context. METHODS AND MATERIALS: This is a retrospective study of patients with metastatic Pca, diagnosed at King Hussein Cancer Center, Jordan, between 2006 and 2018. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Factors that significantly affected overall survival (OS) in the univariable analysis were examined in a multivariable Cox regression analysis. RESULTS: A total of 188 patients with metastatic Pca were included in this analysis, of whom 168 (89%) had de novo metastatic disease. The median age at diagnosis was 68 years, 144 (77%) had bone metastasis, 32 (17%) had visceral metastasis, and 126 (67%) had high-volume disease. At a median follow-up of 67 months, the median OS was 44.3 months. The following factors predicted inferior OS in univariable analysis: smoking, normal BMI, high-volume disease, high alkaline phosphatase (ALP), previous local therapy for prostate, and orchiectomy versus medical androgen deprivation therapy (ADT). On multivariable analysis, high-volume disease (hazard ratio [HR], 1.92 [95% CI, 1.17 to 3.13]; P = .0094), high ALP (HR, 2.136 [95% CI, 1.38 to 3.31]; P < .001), and orchiectomy (HR, 2.40 [95% CI, 1.51 to 3.82]; P < .001) emerged as independent factors for inferior OS. CONCLUSION: Metastatic Pca outcomes in our population closely align with the global benchmark. High volume status, elevated ALP, and performance of surgical as opposed to medical ADT emerge as prognostic indicators of poor survival.

Germline Genetic Mutations in Adult Patients with Sarcoma: Insight into the Middle East Genetic Landscape.

Data on germline mutations in soft tissue and bone sarcomas are scarce. We sought to identify the prevalence of germline mutations in adult sarcoma patients treated at a tertiary cancer center. Newly diagnosed patients were offered germline genetic testing via an 84-gene panel. The prevalence of pathogenic germline variants (PGVs) and their association with disease-, and patient- related factors are reported. A total of 87 patients were enrolled, the median age was 48 (19-78) years, and 47 (54%) were females. Gastrointestinal stromal tumors (n = 12, 13.8%), liposarcoma (n = 10, 11.5%), and Ewing sarcoma (n = 10, 11.5%) were the main subtypes. A total of 20 PGVs were detected in 18 (20.7%) patients. Variants of uncertain significance, in the absence of PGVs, were detected in 40 (45.9%) patients. Young age (p = 0.031), presence of a second primary cancer (p = 0.019), and female gender (p = 0.042) were correlated with the presence of PGVs. All identified PGVs have potential clinical actionability and cascade testing, and eight (44.44%) suggested eligibility for a targeted therapy. Almost one in five adult patients with soft tissue and bone sarcomas harbor pathogenic or likely pathogenic variants. Many of these variants are potentially actionable, and almost all have implications on cancer screening and family counselling. In this cohort from the Middle East, younger age, presence of a second primary tumor, and female gender were significantly associated with higher PGVs rates. Larger studies able to correlate treatment outcomes with genetic variants are highly needed.

Prophylactic Cranial Irradiation prior to HCT for Acute Lymphoblastic Leukemia: To Boost or Not To Boost.

Background: Total body irradiation (TBI) with or without cranial radiation boost (CRB) is an integral component of conditioning prior to allogeneic hematopoietic cell transplantation (allo-HCT) in acute lymphoblastic leukemia (ALL). The benefit of CRB is not yet established. Methods: This is a retrospective single center cohort study. Between January of 2003 and April of 2019, electronic medical records of 166 patients with ALL were retrospectively reviewed. One hundred forty-three patients with ALL and no prior central nervous system (CNS) involvement were included. Patients were divided into two cohorts according to cranial radiation boost (cohort-1: CNS-/CRB+ (110/143, 77%) and cohort-2: CNS-/CRB- (n=33/143; 23%). No patients received post-transplant prophylactic intrathecal chemotherapy. Results: Following alloHCT, 15 patients (10.5%) experienced relapse; 11 relapses (10%) in cohort-1, and 4 (12%) in cohort-2. Four patients (26.6%) experienced systemic medullary relapse with initial central nervous system (CNS) involvement. One patient (6.6%) experienced isolated first central nervous system relapse after allotransplant with no difference between the two cohorts (6.6% vs 0; P-0.59). Age at transplant and phenotypic subtype were predictive of first central nervous system relapse after allotransplant with respective P-values of 0.001 and 0.015.At a median follow-up of 30 months (range: 2.5-128 months), the estimated 3-year overall survival was 61% (95% CI: 53-69), relapse free survival was 60% (95% CI: 52-69) and 3-year central nervous system-relapse-free survival was 99% and 100% in in cohort-1 and cohort-2 respectively, when systemic relapses were censored. There was no statistical significant difference in either survival or relapse free survival between the two cohorts (P > 0.69). Conclusions: Our results suggest that augmenting total body irradiation with cranial radiation boost in patients with ALL with no prior CNS involvement did not improve relapse risk in central nervous system or survival outcomes.

Clinical outcomes and impact of prognostic factors in resectable oral cavity squamous cell carcinoma.

Purpose: To evaluate clinical outcomes and prognostic factors in non-metastatic oral cavity squamous cell carcinoma (OCSCC) patients who underwent surgery with or without adjuvant therapy. Methods: From 2007 and 2018, 116 patients were analyzed. The primary endpoint was overall survival (OS), and secondary endpoints were disease-free survival (DFS), local failure (LF), regional failure (RF), and distant metastases (DM). Kaplan-Meier method and log-rank test assessed survival outcomes, while Cox proportional hazard tests analyzed prognostic factors. Results: Median patient age was 53 years, most were smokers (93.5%) and males (62.9%). Predominant subsite was the oral tongue (58.6%). Treatment included surgery alone (16.4%), adjuvant radiotherapy (46.6%), or adjuvant concurrent chemoradiotherapy (CCRT) (37%). The median follow-up time was 45.9 months. There were significant differences between groups in terms of gender (P=0.028) and RT dose (P=0.01). The 3-year OS, DFS, LF, RF and DM for the entire cohort were 60.9%, 55.1%, 20.11%, 8.43%, and 17.13%, respectively. Surgery alone yielded higher 3-year OS (81.4%) than adjuvant RT (70%) or adjuvant CCRT (41.4%), (p=0.012). Adjuvant CCRT correlated with higher LF compared to adjuvant RT and surgery alone groups (p=0.029). Lymphovascular invasion (LVI) impacted OS (HR=2.034, p=0.0498) and DM (HR=3.380, p=0.0132), while higher tumor grade increased DM likelihood (HR=8.477, p=0.0379). Conclusions: This study reports OCSCC patient outcomes in Jordan across different treatment modalities. Adjuvant CCRT correlated with higher LF rates, and LVI impacted OS and DM, aligning with existing OCSCC treatment literature.

From Despair to Hope: First Arabic Experience of 177Lu-PSMA and 161Tb-PSMA Therapy for Metastatic Castration-Resistant Prostate Cancer.

The objective of this retrospective study is to assess the effectiveness and safety of two beta-emitting prostate-specific membrane antigen (PSMA) radioligands, [177Lu]Lu and [161Tb]Tb, in heavily treated patients with metastatic castration-resistant prostate cancer (mCRPC). A total of 148 cycles of beta-emitting PSMA radioligand therapy were given to 53 patients at a specialized cancer care center in Amman, Jordan. This treatment was offered following the exhaustion of all prior treatment modalities. Approximately half of the cases (n = 26) demonstrated an initial partial response to PSMA radioligand therapy. Moreover, roughly one-fourth of the patients (n = 13) exhibited a sustained satisfactory biochemical response, which qualified them to receive a total of six PSMA radioligand therapy cycles and maintain continued follow-up for additional treatment cycles. This was reflected by an adequate prostate-specific antigen (PSA) decline and a concomitant partial response evident on [68Ga]Ga-PSMA positron emission tomography/computed tomography imaging. A minority of patients (n= 18; 34%) experienced side effects. Generally, these were low-grade and self-limiting toxicities. This study endorses previous research evidence about PSMA radioligand therapy's safety and efficacy. It also provides the first clinical insight from patients of Arab ethnicity. This should facilitate and promote further evidence, both regionally and internationally.

Peer Review in Radiation Oncology: Where Does the Middle East, North Africa, and Türkiye Region Stand?

PURPOSE: This study aims to assess the status of radiation oncology peer review procedures across the Middle East, North Africa, and Türkiye (MENAT) region. METHODS: A cross-sectional electronic survey was conducted among radiotherapy centers in the MENAT region in March 2024. It assessed peer review practices, departmental demographics, perceived importance of peer review, and potential barriers. RESULTS: Data from 177 radiation oncology centers revealed varying peer review implementation across the MENAT region. Egypt had the highest participation (16.4%) among all responders. Most centers (31%) treated 500-1,000 cases annually. The majority (77.4%) implemented peer review, with varying levels between countries and across different centers. Advanced radiotherapy techniques significantly correlated with implementation of peer review (P < .05). Peer review meetings were mostly scheduled on a weekly basis (46%) and organized by radiation oncologists (84.7%). Target volume contouring (89%) and radiotherapy prescription (82%) were frequently peer-reviewed. Respondents with peer review at their institutions significantly valued peer review for education, adherence to guidelines, improving planning protocols, and reducing variation in practice institutions without peer review (P < .05). The most frequently reported barriers to peer review were having a high number of patients (56%) and shortage of time (54%). CONCLUSION: Peer review is essential for improving the quality of practice in radiation oncology. Despite some discrepancies, numerous obstacles, and challenges in implementation, it is instrumental in the improvement of patient care in most centers throughout the region. Raising awareness among radiation oncologists about the importance of peer review is paramount to lead to better outcomes.

Patterns and Frequency of Pathogenic Germline Variants Among Prostate Cancer Patients Utilizing Multi-Gene Panel Genetic Testing.

Background: Germline genetic testing (GGT) has significant implications in the management of patients with prostate cancer (PCa). Herein, we report on patterns and frequency of pathogenic/likely pathogenic germline variants (P/LPGVs) among newly diagnosed Arab patients with PCa. Methods: Patients meeting the National Comprehensive Cancer Network (NCCN) eligibility criteria for GGT were offered a 19-gene PCa panel or an expanded 84-gene multi-cancer panel. Results: During the study period, 231 patients were enrolled; 107 (46.3%) had metastatic disease at diagnosis. In total, 17 P/LPGVs were detected in 17 patients (7.4%). Among the 113 (48.9%) patients who underwent GGT with the 19-gene panel, eight (7.1%) had P/LPGVs, compared to nine (7.6%) of the 118 (51.1%) who did GGT through the expanded 84-gene panel (P = 0.88). Variant of uncertain significance (VUS) rate was higher (n = 73, 61.9%) among the group who underwent expanded 84-gene panel testing compared to those who underwent the 19-gene PCa panel (n = 35, 30.9%) (P = 0.001). P/LPGVs in DNA damage repair (DDR) genes, most frequently BRCA2, CHEK2 and TP53, were the most common P/LPGVs findings. Conclusion: This study is the first to characterize the germline genetic profile of an Arab population with PCa. All detected P/LPGVs were potentially actionable, with most variants able to be detected with a PCa-specific panel.

Implementation of Universal Pan-Cancer Germline Genetic Testing in an Arab Population: The Jordanian Exploratory Cancer Genetics Study.

PURPOSE: Germline genetic testing (GGT) significantly affects cancer care. While universal testing has been studied in Western societies, less is known about adoption elsewhere. MATERIALS AND METHODS: In this study, 3,319 unselected, pan-cancer Jordanian patients diagnosed between April 2021 and September 2022 received GGT. Pathogenic germline variant (PGV) frequency among patients who were in-criteria (IC) or out-of-criteria (OOC; 2020 National Comprehensive Cancer Network criteria) and changes in clinical management in response to GGT results were evaluated. Statistical analysis was performed using two-tailed Fisher's exact test with significance level P < .05. RESULTS: The cohort was predominantly female (69.9%), with a mean age of 53.7 years at testing, and 53.1% were IC. While patients who were IC were more likely than patients who were OOC to have a PGV (15.8% v 9.6%; P < .0001), 149 (34.8%) patients with PGVs were OOC. Clinical management recommendations in response to GGT, including changes to treatment and/or follow-up, were made for 57.3% (161 of 281) of patients with high- or moderate-risk PGVs, including 26.1% (42 of 161) of patients who were OOC. CONCLUSION: Universal GGT of patients with newly diagnosed cancer was successfully implemented in Jordan and led to identification of actionable PGVs that would have been missed with guidelines-based testing.

Doxorubicin Dose Deintensification in Pediatric Osteosarcoma, Is Less Better?

Hadeel HalalshehIntroduction We implemented new clinical practice guidelines (CPG) for patients with osteosarcoma starting in January 2009. These guidelines were based on standard European and American Osteosarcoma Study regimen, which includes six cycles of doxorubicin with a cumulative dose of 450 mg/m 2 . Aiming to reduce cardiac toxicity at our center, we opted to reduce the cumulative dose of doxorubicin to 375 mg/m 2 . Materials and Methods This is a retrospective cohort of osteosarcoma patients aged <18 years, treated at our center between 2009 and 2018. Patients were treated with unified CPG and were prospectively followed. Disease and treatment characteristics were depicted, and survival rates were calculated. When needed, comparison of survival of different groups were conducted using log-rank test. Results After a median follow-up of 43.3 months (range, 2-153 months), 79 patients were diagnosed with osteosarcoma and treated with dose-reduced doxorubicin. Median age at diagnosis was 12.8 years. At diagnosis, 58 patients (73%) had localized disease. The 5-year event-free survival (EFS) for the whole group was 50 ± 5.9%, and overall survival (OS) was 64 ± 5.7%. For patients with extremity nonmetastatic tumors ( N = 56), 5-year EFS and OS were 60 ± 6.9% and 70 ± 6.8%, respectively, and for this group of patients, response to chemotherapy was associated with better EFS ( p = 0.0048) and OS ( p = 0.013). Only two patients suffered transient cardiac dysfunction, which was resolved after treatment. Conclusion Our findings suggest that deintensification of doxorubicin may provide adequate control for pediatric osteosarcoma. In the absence of large randomized clinical trials addressing this issue, developing countries with less resources to treat patients with heart failure may consider using the lower dose.

Fluorodeoxyglucose positron emission tomography (18F-FDG PET)-computed tomography (CT) in the initial staging of bladder cancer: a single institution experience.

BACKGROUND: The purpose of this study was to assess the usefulness of fluorodeoxyglucose positron emission tomography (18F-FDG PET)-computed tomography (CT) scan for staging urinary bladder cancer. The study also sought to determine the effect of 18F-FDG PET/CT on management decisions and its implications for patient care. METHODS: A total of 133 patients with bladder cancer who had both conventional imaging and 18F-FDG PET/CT for initial staging were identified. All 18F-FDG-PET/CT findings were classified as true positive, true negative, false positive, or false negative based on their potential to impact the intent of treatment. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated using the standard definition. Furthermore, the rate of change in therapy intent was determined for the entire sample and for subgroups with non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC) patients. RESULTS: The overall concordance rate between PET/CT and conventional imaging was around 54%. On conventional images, 18% of patients had localized disease, which was upstaged in 6.8% of cases using 18F-FDG PET/CT. Pelvic lymph node involvement was detected in 18.8% of cases using conventional imaging, which was downstaged to localized disease in 4.5% of cases using 18F-FDG PET/CT. While 63.2% of patients had systemic disease on a CT scan, 24.7% of cases were downstaged using PET/CT. Overall, the rate of change in therapy intent was 26.3% for the entire sample, 24.5% for NMIBC subgroup, and 27.3% for MIBC patients. CONCLUSIONS: The study found that 18F-FDG PET/CT is an effective and accurate tool for staging bladder cancer in newly diagnosed patients. Approximately one quarter of patients had a change in management intent based on 18F-FDG PET/CT results. The study suggests that PET/CT should be used as a standard for newly diagnosed patients, but more research is needed to confirm this.

Molecular Imaging in Recurrent Prostate Cancer Presented as a Mixed Small Neuroendocrine Tumor/Acinar Adenocarcinoma.

Molecular imaging is an important tool for evaluating patients with prostate cancer, including those with hybrid histopathology. Although rare, mixed small neuroendocrine tumor/acinar adenocarcinoma exhibit aggressive behavior that necessitates optimal therapy. Molecular imaging has been implemented previously to assess radioligand therapy eligibility in such cases. Interestingly, the uptake of radiotracers targeting prostate-specific membrane antigen (PSMA) and somatostatin receptor may be reduced and can potentially lead to false negative readings in certain tumor types with hybrid features. Therefore, physicians should be aware of different kinds of disparities when assessing these tumor types with the aforementioned modalities.

Bladder cancer in young adults: Disease and treatment characteristics of patients treated at a tertiary cancer center.

Objectives: The incidence of bladder cancer in the Middle East is increasing. Nevertheless, data on the young population with urothelial carcinoma (UC) of the urinary bladder in this region is scarce. Therefore, we evaluated clinical and tumor characteristics, in addition to treatment details in patients younger than 45 years old. Methodology: We reviewed all patients presenting with UC of the urinary bladder from July 2006 to December 2019. Clinical characteristics including demographics, stage at presentation, and treatment outcomes were extracted. Results: Out of 1272 new cases of bladder cancer, a total of 112 (8.8%) patients were ≤45 years old. Seven patients (6%) had nonurothelial histology and were excluded from the study. The remaining 105 eligible patients with UC had a median age at presentation of 41 years (35-43). Ninety-three patients (88.6%) were males. Tumor stage at presentation: nonmuscle invasive disease (Ta-T1), locally advanced muscle-invasive bladder cancer (MIBC) (T2-3), and metastatic disease were 84.7%, 2.8%, and 12.5%, respectively. All patients with MIBC received neoadjuvant cisplatin-based chemotherapy. Radical cystectomy was performed in 8 (7.6%) cases; three patients with MIBC and five with high-volume non-MIBC. Neobladder reconstruction was done in six patients. A total of 13 patients with metastatic disease (93%) received palliative chemotherapy (gemcitabine/cisplatin), and one (7%) was a candidate for best supportive care only. Conclusion: Bladder cancer is relatively rare in the young population, although the incidence at our region is higher than other reports in the literature. Most patients present with early disease. Early diagnosis and multidisciplinary approach are paramount for the management of these patients.