Well-Differentiated Neuroendocrine of Left Kidney.

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Spindle Cell Neoplasms of Pancreas.

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Treatment Related Acute Toxicities Between Treatment with 3D-CRT and IMRT in Localised Prostate Cancer.

OBJECTIVE:  To compare the acute toxicities of two radiation treatment techniques, intensity modulated radiation therapy (IMRT), and 3-dimensional conformal radiation therapy (3D-CRT) in localised prostate adenocarcinoma. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Oncology, Dr. Ziauddin Hospital, Karachi, Pakistan, from July 2016 to June 2022. METHODOLOGY: Patients with localised prostate adenocarcinoma who underwent treatment using two different advanced radiotherapy techniques i.e., IMRT and 3D-CRT were recruited during the study period. They were followed up for six months for acute gastrointestinal (GI) and genitourinary (GU) adverse events (acute toxicities) related to both treatment modalities according to Modified radiation therapy oncology group (RTOG) criteria. The acute toxicities were assessed at the 2nd, 4th, and 6th week during treatment and at the 3rd and 6th month after treatment. RESULTS:  There were 78 patients, with 39 patients in each group. The mean age was 68 ± 10 years in the 3D-CRT and 68 ± 07 years in the IMRT group. Patients in the IMRT group exhibited markedly lower treatment-related acute GI and GU effects at the end of 4th and 6th weeks for anorectal pain (p = 0.04) and (p = 0.01) and burning micturition (p = 0.003) and (p = 0.01), respectively. Furthermore, at 3 months anorectal pain (p = 0.02), loose stools (p = 0.005), and burning micturition (p = 0.01) were present and at 6 months anorectal pain was (p = 0.01) still present. CONCLUSION: Radiation therapy modalities 3D-CRT and IMRT both showed acceptable toxicity profile in the management of localised prostate cancer, while IMRT group exhibited significantly lower treatment-related acute GI and GU effects. KEY WORDS: 3D-CRT (3-Dimensional Conformal Radiation Therapy), IMRT (Intensity-Modulated Radiation Therapy), Radiation toxicity.

Low Dose Sorafenib in Gastric Gastrointestinal Stromal Tumour with PDGFRA p.1843-D846 Deletion in an 88-Year-Old Male.

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Palbociclib: Safe and Effective in an 85-Year-Old Female with Metastatic Bilateral Breast Cancer.

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Spinal Myeloid Sarcoma in a Non-Leukaemic Patient.

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Non-Seminomatous Germ Cell Tumour in situ of Testis with Extensive Metastases.

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Leiomyosarcoma of the Inguinal Canal: A Rare Disease.

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Impact of Radiation Therapy After High Dose Chemotherapy and Autologous Hematopoietic Stem Cell Transplantation in Patients With Relapsed/Refractory Lymphomas: A Single Center Experience.

INTRODUCTION: After high dose chemotherapy (HDC) and autologous stem cell transplantation (auto-SCT), in patients with relapsed/refractory diffuse large B cell lymphoma (DLBCL) and Hodgkin lymphoma (HL), involved field radiation therapy (RT) for consolidation and residual/progressive disease (PD) eradication is a common practice. MATERIALS AND METHODS: Retrospective single-institution cohort analysis to evaluate the impact of early RT after HDC auto-SCT. RESULTS: Between 1996 and October 2019, 153 patients (43 DLBCL, 110 HL) underwent RT after HDC auto-SCT. Males 95 (62%), females 58 (38%), median age 24 years. Indications for RT was consolidation 65%: residual disease eradication 16%: and PD eradication 19%. For DLBCL, the median overall survival (OS) for the above indications was not reached (NR):NR:2 months and the KM 5-year OS was 72.6%:64.3%:12.5% respectively (P ≤ .000). Pair-wise analysis showed that consolidation versus residual disease eradication had no difference (P = .88) but both were superior to PD disease eradication (P ≤ 000 and P = .005 respectively). For HL, indication for RT was, 54%:23%:24% respectively. The median OS was NR:NR:28.8 months and KM 5-year OS was 82.3%:78%:30% respectively (P ≤ .000). Pair-wise analysis showed that consolidation versus residual disease eradication had no difference (P = .98) but both were superior to the PD eradication group (P ≤ 000). RT was well tolerated with no significant long-term toxicity. CONCLUSION: Post HDC auto-SCT RT was well tolerated. DLBCL and HL patients with residual disease treated with the RT had similar long-term survival as those who received RT for consolidation. RT failed to improve the poor survival in patients with post-HDC auto-SCT PD.

Breast Cancer with Metastases to Coronary Arteries.

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A Case of Diffuse Large B-cell Lymphoma with Cardiac Involvement Incidently Diagnosed on Cardiac Imaging.

Cardiac lymphomas, either primary or secondary, are mostly of B-cell lineage; among which, diffuse large B-cell lymphoma (DLBCL) is the most common. Secondary involvement of the heart is usually a late manifestation of disseminated lymphoma. Patients may be asymptomatic or may have non-specific symptoms, particularly when cardiac involvement is not extensive. A 22-year male patient presented with four months' history of progressive enlargement of left cervical lymph nodes with intermittent fever along with dysphagia and left ear pain. Positron-emission tomography (PET)/computed tomography (CT) scan revealed abnormal fluorodeoxyglucose (FDG) uptake in multiple systemic locations including inferior wall of the myocardium. Subsequently, cardiac MRI showed left ventricular posterolateral wall abnormal area of delayed enhancement, corresponding to the FDG uptake on PET CT scan. Patient had remission after completion of standard chemotherapy protocol for the management of DLBCL with acceptable toxicity. Key Words: Diffuse large B-cell lymphoma (DLBCL), Secondary, Heart, Chemotherapy.

Comparison of 18F-labelled fluoro-2-deoxyglucose-PET with conventional computed tomography for staging and response assessment in paediatric and adult patients with nodular lymphocyte-predominant Hodgkin's lymphoma.

BACKGROUND: Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is an uncommon subtype of Hodgkin lymphoma. Data are limited regarding 18F-labelled fluoro-2-deoxyglucose (FDG)-PET use in NLPHL. We are reporting our experience with FDG-PET utility in staging and response assessment NLPHL patients. METHODS: We retrospectively studied a population of all newly diagnosed or relapsed/refractory patients who underwent both pre-treatment contrast-enhanced computed tomography (CeCT) and an FDG-PET and also at the end of planned treatment. RESULTS: We identified 68 patients found to have in total 312 scans, 78 paired pre-therapeutic and post-treatment CeCT and FDG-PET scans. Among them, 55 were male, with a median follow-up was 48 months. Median SUV-max was 8.3 (2.0-21.0). FDG-PET and CeCT were concordant in 80% (62/78) of staging scans. In 20% (16/78) of patients in whom a discordance was observed, FDG-PET resulted in upstaging in 13 scans and downstaging in 3 scans. The sensitivity of CeCT was 92% for nodal staging and 42% for extralymphatic staging when compared to FDG-PET. The specificity of CeCT was 98% as compared to FDG-PET. For response assessment, there was poor agreement between the CeCT and FDG-PET in assigning complete remission of disease scores as FDG-PET was able to identify the absence of disease despite the presence of a radiologically evident residual mass on CeCT. The sensitivity for CeCT compared to FDG-PET was 100% while the specificity was 43% for detection of post-treatment response. CONCLUSION: For NLPHL, pre-therapeutic FDG-PET scan is better than CeCT staging. FDG-PET has much better specificity for response assessment than CeCT.

Single-Institute Review of HER-2/Neu-Positive Invasive Lobular Breast Carcinoma in an Arab Population.

BACKGROUND Invasive lobular carcinoma is special subtype of breast cancer that has clinical behavior and morphology distinct from other breast cancer subtypes. It accounts for 5-15% of breast cancer. Overall, HER-2 gene amplification occurs at a significantly lower rate in ILC, but also has been linked to adverse outcomes. Most cases of ILCs with HER-2 overexpression and or amplification generally have the pleomorphic variant. We report the first series of cases from Saudi Arabia for this rare cancer in an Arab population. CASE REPORT Nine patients retrospectively were evaluated with HER-2/neu-positive ILC of the breast that were diagnosed and managed from 2003 to 2020. Four patients were diagnosed as early breast cancer, 3 had metastatic disease and 2 were locally advanced at their initial presentation. The mean age was 58 years; 30% were classic ILC and another 60% were of mixed non-classic variants (histologic pattern represented by nuclear pleomorphism). Management of patients with HER-2-positive ILC was performed according to standard multimodality breast cancer guidelines, consisting of surgery, chemotherapy with anti-HER-2/neu blockade, radiation, and endocrine therapy, based on stage and hormone status. CONCLUSIONS In conclusion, HER-2-positive invasive lobular carcinoma of the breast is uncommon in the Arab population, which has not been previously reported in the literature. Further studies are warranted to explore the biology, molecular characteristics, and clinical course in this group of patients.

Behavior and Outcomes of Pregnancy Associated Breast Cancer

Introduction: Pregnancy Associated Breast cancer (PABC) is associated with poor prognosis and a decreased overall survival. A retrospective review was conducted to review the experience and outcome in a tertiary care hospital, and to compare those seen in a matched group for year of diagnosis. Materials and Methods: This is a retrospective review of a prospectively collected breast cancer registry. The study was conducted in a tertiary care hospital in Riyadh, Saudi Arabia from January to Decamber 2014 . Female patients with PABC were identified and matched with similar cohort of non-pregnant breast cancer patients that were diagnosed between 2001-2010. Clinical data including age, tumor biology, clinical stage, follow up and outcomes (disease free survival, DFS) were analyzed and compared between the two groups using SAS 9.3 and R-2.14.1 Results: A total of 110 patients in Group 1 and 114 patients in Group II were analyzed. In both groups, the patient age ranged was between 20 to 45 years; the median follow up was 34 months in PABC and 54 months in non-pregnant cohort. PABC were statistically more likely to be triple negative (p value-0.05) and diagnosed at advanced stage (stage 3 and 4) (p value-0.02). There was no difference in the occurrence of Her-2 positive disease. In pregnant patients there was a 5-year survival rate of 65% compared to non-pregnant cohort of 82% with p value of 0.002 and DFS was also 47.5% versus 65.4% with a p value .002 which is statistically significant. Conclusion: Pregnancy associated breast cancer (PABC) is diagnosed at a more advanced stage and tends to be triple negative and they are associated with a worse DFS and overall survival. Early detection during pregnancy may improve outcome.

Knowledge and Perceptions about Cancer Treatment-associated Infertility among Young Patients at a Tertiary Care Hospital in Pakistan

Introduction: Infertility after cancer treatment can cause significant emotional stress and grief for cancer survivors. In this study we assessed knowledge and perceptions among young cancer patients regarding the topic of cancer and infertility related to different treatment options. Material and Methods: This cross-sectional study was conducted on young cancer patients in the Clinical Oncology Department, JPMC, Karachi, from January to August 2013. Patients were requested to fill in questionnaires. Comparisons between gender and age groups were performed using the Student's t test and Pearson's Chi-squared. Significance was concluded with a two tailed p-value less than 0.05. Results: The survey included 368 cancer patients, 194 males and 174 females. Ninety percent of respondents of either gender were not aware that cancer or cancer treatment can cause infertility, this being age dependent (P=0.06). However, on being made aware, 98% of males and 91% of females wanted their oncologist to discuss treatment-related infertility prior to initiating cancer treatment (P=0.005) and 92% and 78%, respectively, wanted to consider fertility preservation techniques prior to treatment (P<0.0001). Of age groups 15-30 years and 31-50 years, 91 % and 81% wanted to consider FP prior to cancer treatment (P =0.011). Among 226 married individuals, 89% males and 79% females underestimated that effects that infertility issues might have on their relationships with their spouses. Conclusions: We recommend physicians and oncology care givers to initiate discussion of the topic of cancer and treatment-related infertility with young cancer patients during their initial management planning.

Outcomes of High Risk Patients with Febrile Neutropenia at a Tertiary Care Center

Fever during chemotherapy-induced neutropenia continues to be a major cause of morbidity and mortality in cancer patients. Mortality depends on the duration and degree of neutropenia, bacteremia, sepsis, performance status, comorbidities and other parameters. The highest mortality rates in cancer patients hospitalized with febrile neutropenia (FN) are observed in those with documented infection. The objectives of the study were to present available tools for risk assessment, to review pathogens causing infections in adult FN patients and to assess outcomes. Methods: This cross sectional study was conducted on adult culture positive FN patients admitted to the Hematology/Oncology service at the Aga Khan University Hospital, Karachi, Pakistan from 1st January 2009 to 31st December 2012. Highrisk criteria were defined as profound neutropenia, short latency from a previous chemotherapy cycle, sepsis or clinically documented infection at presentation, severe co-morbidity and a performance status greater than or equal to 3. All types of organisms in blood culture and the outcomes of the patients were recorded on Proforma. Results: A total of 156 patients with culture-positive febrile neutropenia were identified during the study period. The mean age was 47 years with a slight male predominance of 54%. One hundred and sixteen patients fulfilled the criteria for the high risk group. Fifty two percent had a single high risk factor and 40 % had two. All patients harbored either single or multiple bacterial organisms including gram positive, gram negative or both types. Some 34% of patients had gram positive bacteremia, 57 % had gram negative and 9 % were infected with both. Among 73 gram positive cultures 44 % were Staphylococcus species and among 123 gram negative cultures 43 % were E. coli. One hundred and fifteen patients recovered uneventfully and could be discharged. Thirty two patients in the high risk and 9 in the low risk groups deceased with an overall mortality of 26 %. The mean hospital stays of patients with solid tumors and hematological malignancies were 7.58 and 15.0 days, respectively. Mortality was higher in the latter group, and also in high risk patients with both gram positive and negative bacteremia. Conclusion: We emphasize the importance of risk stratification and continuous surveillance of the spectrum of locally prevalent pathogens and their susceptibility patterns for formulation of therapeutic regimens for febrile neutropenic patients.

Proptosis of eye: an atypical presentation of prostatic malignancy.

Orbital metastasis is a rare occurrence found only in about 3 - 10% of all prostate cancers. A 72 years male presented with proptosis of the left eye associated with pain, blurred vision and frequent headaches for the past 8 months. Past medical history had symptoms of bladder outflow obstruction for 3 years. MRI brain and orbit with contrast was consistent with a large soft tissue mass in the left frontal region. The mass was surgically excised in order to achieve palliation. Histopathology revealed poorly differentiated malignant neoplasm with immunohistochemistry favoring metastatic prostate carcinoma. Postoperative radiotherapy was administered with a palliative intent. CT scan identified an enlarged prostate with a nodular lesion, abdominal lymphadenopathy and soft tissue density lesion in the apical segment of left lung. Serum PSA level was 149 µg/L. Bone scan was also consistent with metastatic disease.

Single centre study of using bendamustine in the treatment of B-cell malignancies.

OBJECTIVE: To evaluate the experience of bendamustine in the treatment of B-cell malignancies at a tertiary care centre. METHODS: The retrospective descriptive analysis included data of all adult patients with B-cell malignancies treated with bendamustine from 2009 to 2011 at the Aga Khan University Hospital, Karachi. Data was analysed using SPSS 17.0. Frequencies and percentages were computed for baseline characteristics, responses and toxicities. RESULTS: Of the 19 patients 15 (79%) were males and 4 (21%) were females.The mean age was 59.53+/-12.14 (with a range of 46-86). Eight (42%) had follicular lymphoma, 6 (32%) had mantle cell lymphoma, 2 (11%) had diffuse large B-cell lymphoma, and 3 (16%) had chronic lymphocytic leukaemia. Four (21%) patients experienced grades 3 and 4 cutaneous toxicities. Eight (42%) patients were treated with bendamustine as first-line therapy. Six of them (75%) were included for response evaluation; 3 (50%) had complete response, and 3 (50%) had partial response. Eleven (58%) patients had relapsed disease out of which 3 (27.27%) had complete response, and 7 (63.63%) had partial response, whereas 1 (9%) had disease progression. CONCLUSION: Bendamustine given as monotherapy or in combination is safe and useful in the treatment of patients with B-cell malignancies.

Temozolomide for relapsed primary CNS lymphoma.

Primary CNS lymphoma (PCNSL) is an aggressive form of non-Hodgkin's lymphoma that accounts for 3% of all primary brain tumours. No clear risk factors for PCNSL in immunocompetent patients are known. The disease is more common in men and in elderly persons. Patients with AIDS who have low CD4+ counts are at the greatest risk for PCNSL. Virtually all PCNSLs in patients with AIDS express an Epstein-Barr virus (EBV)-related genome. PCNSL is less frequently associated with EBV in patients without AIDS. A 42 years old gentleman diagnosed with primary CNS lymphoma with negative serological test for human immunodeficiency virus was initially treated with Modified De Angelis protocol relapsed after treatment. He underwent gamma knife stereotactic surgery which lead to further deterioration clinically and progression of disease on imaging. Later, he was treated with salvage high dose methotrexate, but after completion of six cycles there was a radiological progression of disease. Relapsed disease was further treated with a single agent temozolomide and the disease went in remission.