Evaluation of Temporal Virological Responses to Interferon-α-2b plus Ribavirin among Genotype 3a Hepatitis C Virus-Infected Patients.

OBJECTIVES: The present study aimed to examine the impact of rapid virological response (RVR) and early virological response (EVR) on sustained virological response (SVR) in chronic hepatitis C genotype 3a individuals. METHODS: The patients were given antiviral therapy with IFN-α-2b, 3 million units 3 times a week and 800-1,200 mg of ribavirin daily adjusted to the patient's body weight (<60 kg 800 mg day-1, and >60 kg 1,200 day-1). The patients received this combination therapy for 24 weeks. The patients were evaluated for their viral load at week 4, 12, and 24 using RT-PCR. RESULTS: Out of 1,471 patients, 43.3% showed a negative viral load in week 4, demonstrating RVR, whereas 56.6% maintained a high viral load. These were further separated based on viral reduction in their plasma: either negative for HCV-RNA at week 12 (n = 575), manifesting EVR, or showing a 2-log reduction in HCV viral load classified as partial EVR (PEVR; n = 259). The PEVR response was less (29.7%) compared with RVR (85.9%) and EVR (69.0%), although nonresponders were found in both groups. CONCLUSIONS: Individuals incompliant with their treatment who have a higher RVR significantly influence their SVR towards a better remission that can be treated within a short duration with standard treatment.

Optimum predictors of therapeutic outcome in HCV patients in Pakistan.

Hepatitis C virus (HCV) constitutes a major public health issue in Pakistan. Interferon α and ribavirin is used widely in routine practice in HCV infected patients in Pakistan.Treatment prediction is an important tool in therapy management. The present study aims to evaluate trends of predictive variables of treatment outcome in patients with different genotypes. The analysis comprised of 921 patients infected with different HCV genotypes. All the patients received IFN α-2b combined with ribavirin for 24 weeks. Overall, 60.2% patients achieved Sustained virologic response (SVR). In females sustained virologic response (SVR) was higher in age group <40 years (77.2%) than ≥40-50 years (60%) but in male SVR was almost equal in both age groups. We also found higher SVR with low pretreatment viral load (72.4%, P < 0.0001). Sustained Virologic Response in genotype 3a was 63.1%, 3b was 55%, 1a was 36.3% and 1b was 35% 3a +3b was 55.0% and 1a+3a was 42.9%. According to multivariable logistic regression analysis age < 40 years (2.0; 95%CI, 1.49-2.84; P = 0.0001), low pretreatment RNA level<800,000 IU/ml (4.0; 95%CI, 2.64-6.17; P = 0.0001), early virologic response at week 12 (12.3; 95%CI, 8.18-18.58; P < 0.0001) and non-fatty liver (2.5; 95%CI, 3.6-6.2; P = 0.005) showed significance for SVR. Nucleotide substitution in 5'UTR before treatment failed to show any characteristic pattern that has correlation with sustained response. Subtype 3a showed 95% presence among patients with age <40 years while older patients showed 79.9%.

Analytical variables influencing the HCV RNA determination by TaqMan real-time PCR in routine clinical laboratory practice.

Hepatitis C virus (HCV) quantification is used as a prognostic marker for treatment success. In a routine clinical laboratory some infinitesimal sample handling factors can contribute to variability and loss of precision in HCV quantification. This may include blood collection tubes, blood drawing procedure, sample processing and storage temperatures. In current study blood was collected in tubes with different anticoagulant type (spray vs. liquid), group 1, blood was drawn with possible suck of methylated spirit through needle (experimental group) while avoiding the methylated spirit suck (control group) group 2, plasma separation was delayed from 0 to 60 min for group 3, plasma storage at different temperatures group 4. All samples were analyzed using Corbett research real time PCR system using AJ Roboscreen Kit. Mean viral load difference between spray vs. liquid was found 3.6 × 10(5) IU/ml (p < 0.001). Methylated spirit inhibited the viral load quantification with a value of 4.8 × 10(5) IU/ml (p < 0.001). Mean viral load difference was found 1.2 × 10(5) IU/ml (p < 0.05). Delay in centrifugation from 0 to 60 min and plasma placement at 25 °C for 15 min before freezing had no effect (p = 0.5996). Plasma storage temperature at -80 and -20 °C did not affect significantly on RNA levels (p > 0.05). In conclusion blood collection tubes and procedures can be a key factor in variability of results, that might affect the treatment response decision.

Long-term survivor of brain metastases from malignant melanoma.

Malignant melanoma is notorious for distant metastases. Median survival for stage IV melanoma is 6-10 months and 5 year survival is less than 5%. Median survival for melanoma with brain metastases is even lower i.e. 2 to 9 months. Here a case is reported who was treated for melanoma of sole of left foot with ipsilateral inguinal adenopathy and brain metastases in 2001 and is still surviving disease-free after a lapse of 8 years.

Hepatic and skeletal metastases from primary intracranial atypical meningioma.

Meningioma constitutes 27% of primary CNS tumours. It rarely metastasizes to distant sites (< 0.1%). Here, we present a case report of primary atypical intracranial meningioma metastasizing to liver and bone after 4 years of surgery and postoperative radiotherapy presenting with multiple episodes of hypoglycemia.

Porocarcinoma: a rare sweat gland malignancy.

Eccrine Porocarcinoma (ECP) is a malignant tumour arising from the intraepithelial ductal parts of the sweat gland. It has also been described as malignant hidroacanthoma simplex, sweat gland carcinoma, malignant intra-epidermal eccrine poroma, eccrine poroepithelioma, dysplastic poroma, malignant syringo acanthoma and porocarcinoma. Treatment with wide local excision but metastatic lesions can be treated with chemotherapy. Here, we present a case report of 52 years old male who presented with a fungating growth on left pre-auricular region that came out to be a case of ECP on histopathological examination.

Therapeutic effects of 20 gray radiotherapy over a week in the management of brain metastases.

OBJECTIVE: To determine the therapeutic effects of 20 Gy over a week in the management of multiple brain metastases. Secondly to determine the toxicity profile and survival at 6th month in patients treated with the above-mentioned protocol. METHODS: This was a single arm interventional study, conducted at Nuclear Medicine, Oncology and Radiotherapy Institute (NORI), Islamabad from May 8, 2006 to May 31, 2007. Thirty patients with multiple brain metastases were inducted in this study. Mean age was 52 +/- 11 years. Fifty Four percent were females and 46% males. After initial workup, all were planned for whole brain radiotherapy. 20 Gy was given to whole brain by two parallel opposed, equally weighted lateral fields in five consecutive daily fractions. Dose per fraction was four Gy. All were followed up for six months for survival. Treatment response was categorized in four different categories i.e., > 50%, approximately 50%, < 50% and no response. RESULTS: It revealed that there was significant effect of treatment with 20 Gy radiotherapy as 76% of the patients during and 80% on the last day of therapy showed > 50% response (p < 0.05). Secondly, median survival of the patients after radiotherapy was two months (p < 0.05). No serious toxicity was noted during this therapy. CONCLUSION: Twenty Gy over a week is highly effective in palliation of symptoms due to multiple brain metastases. In comparison with other studies, this protocol had no significant difference in overall survival and acute toxicity.

The Absence of HCV RNA and NS5A Protein in Peripheral Blood Mononuclear Cells Is a Prognostic Tool for Sustained Virological Response.

Hepatitis C Virus (HCV) infection is a major health concern worldwide. The presence of both HCV viral RNA and NS5A proteins in peripheral blood mononuclear cells (PBMCs) indicate the efficacy of the treatment during sustained virological response (SVR) and end of treatment response (ETR). The main objective of this study was to detect the absence or presence of HCV RNA and NS5A proteins in PBMCs. Blood samples were taken from selected patients (Islamabad, Pakistan) before treatment, at ETR, and during SVR. Two hundred HCV responders to pegylated IFN-α-2a plus ribavirin were selected. HCV RNA was extracted from the patients to determine the viral load by reverse transcription (RT)-polymerase chain reaction before treatment. Out of 200 patients, 152 (76%) and 48 (24%) achieved positive and negative ETR, respectively. Among ETR patients, 134 (88.2%) showed SVR, whereas 18 (11.8%) displayed relapse. The male to female ratio was 92:108 with mean age of 37.4 years. Among 152 ETR-positive patients, 29 (19%) patients' PBMCs were positive for HCV RNA and 27 (17.8%) were positive for NS55A proteins. Patients having HCV RNA in PBMCs showed higher relapse frequency compared with patients lacking it. Similarly, patients having NS5A protein showed significantly higher relapse frequency compared with patients lacking it. All PBMC-positive samples were of genotype 3a. In addition, patients with positive NS5A in their PBMCs showed greater risk of relapse compared with patients having HCV RNA. We conclude that the absence of both viral HCV and proteins can be used as an indicator for diagnosis of SVR in the future.

Gated spect myocardial perfusion scintigraphy for identifying septal perfusion artifacts in left bundle branch block.

OBJECTIVE: To determine the role of gated Single Photon Emission Computed Tomography (SPECT) for accurate assessment of myocardial perfusion scintigraphy (MPS) of patients with left bundle branch block (LBBB). DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Punjab Institute of Nuclear Medicine (PINUM), Faisalabad, Pakistan, from June 2002 to April 2003. PATIENTS AND METHODS: MPS data of patients with LBBB was analyzed. Resting gated SPECT MPS was performed after an injection of 740 MBq 99mTc-MIBI in 10 normal and 25 subjects with LBBB (with low probability of coronary artery disease). Visual and quantitative analyses were done on non-gated (NG), end diastolic (ED), end systolic (ES) images. Calculations included septal to lateral wall ratio (SLR), myocardial thickening (MT=% increase in counts during systole) at end systolic phase and myocardial thickening at peak level (% peak MT). RESULTS: Septal hypoperfusion was noted in 19 (76%) patients on NG images and in only 1 (4%) patient on gated SPECT ED images. On NG images of LBBB group, SLR was lower than in controls (0.68+/-0.07 vs. 0.87+/-0.05, p<0.001). SLR of LBBB patients approached to that of control group in gated SPECT ED data (0.86+/-0.06 vs 0.88+/-0.06, p=ns). Myocardial thickening at ES for septum was markedly lower in LBBB group than in controls (21.83%+/-10.86 vs. 66.32%+/-20.15, p<0.001). CONCLUSION: In patients with LBBB, reduced septal thickening results in artifactual septal perfusion defects. Gating the perfusion scintigraphy and reporting perfusion status on end diastolic frames in LBBB patients can eliminate these artifacts.

Impact of age, tumor size, lymph node metastasis, stage, receptor status and menopausal status on overall survival of breast cancer patients in Pakistan.

BACKGROUND: Survival of breast cancer patients depends on a number of factors which are not only prognostic but are also predictive. A number of studies have been carried out worldwide to find out prognostic and predictive significance of different clinicopathological and molecular variables in breast cancer. This study was carried out at Nuclear Medicine, Oncology and Radiotherapy Institute (NORI), Islamabad, to find out the impact of different factors on overall survival of breast cancer patients coming from Northern Pakistan. MATERIALS AND METHODS: This observational retrospective study was carried out in the Oncology Department of NORI Hospital. A total of 2,666 patients were included. Data were entered into SPSS 20. Multinomial logistic regression analysis was performed to determine associations of different variables with overall survival. P values <0.05 were considered significant. RESULTS: The mean age of the patients was 47.6 years, 49.5% being postmenopausal. Some 1,708 were ER positive and 1,615 were PR positive, while Her 2 neu oncogene positivity was found in 683. A total of 1,237 presented with skin involvement and 426 had chest wall involvement. Some 1,663 had > 5cm tumors. Lymph node involvement was detected in 2,131. Overall survival was less than 5 years in 669 patients, only 324 surviving for more than 10 years, and in the remainder overall survival was in the range of 5-10 years. CONCLUSIONS: Tumor size, lymph node metastases, receptor status, her 2 neu positivity, skin involvement, and chest wall involvement have significant effects whereas age and menopausal status have no significant effect on overall survival of breast cancer patients in Pakistan.

Polymorphism of the IL28B gene (rs8099917, rs12979860) and virological response of Pakistani hepatitis C virus genotype 3 patients to pegylated interferon therapy.

BACKGROUND: The gold standard treatment for chronic hepatitis C virus (HCV) infection is pegylated interferon (PEG-IFN) in combination with ribavirin. Most patients treated with PEG-IFN achieve a sustained virological response (SVR). However host genetic factors play a vital role in the spontaneous and treatment-induced clearance of HCV infection from these infected patients. In the current study, polymorphisms of IL28B (rs8099917 and rs12979860) were analyzed and their association with the virological response to PEG-IFN alpha treatment was determined. METHODS: One hundred and fifty HCV genotype 3 patients were assessed to study the correlation of IL28B with a therapeutic regimen of PEG-IFN alpha plus ribavirin. Twenty patients were excluded due to a refusal to participate in the study and 25 patients failed to meet the inclusion criteria. Of the 105 patients recruited, 49 (46.7%) were male and 56 (53.3%) were female. In order to determine single nucleotide polymorphisms of rs8099917 and rs12979860, the sample was amplified by PCR and then IL28B typing was carried out by restriction fragment length polymorphism (RFLP) followed by standard sequencing. RESULTS: We found three types of genotype in rs8099917 of IL28B: wild-type TT in 60.0% of patients, heterozygous GT minor genotype in 36.2%, and GG in 3.8%. The frequency of the CC genotype of rs12979860 was 54.3%, CT was 37.1%, and TT was 8.6%. Overall, SVR was achieved in 68.6% of patients. A higher SVR was achieved for patients with the favorable genotype CC of rs12979860, with 84.2% as compared to 56.4% and 22.2% for minor genotype CT and TT, respectively (p=0.0001). We did not find a significant association for SVR to antiviral treatment in patients with genotype TT (rs8099917) (71.9%, p=0.36). The rapid virological response (RVR) rate was significantly higher in patients with major genotype TT (88.9%, p=0.04). These results show that IL28B polymorphism is highly associated with SVR to therapy in the Pakistani population infected with HCV genotype 3. CONCLUSIONS: HCV-infected patients carrying homozygous C/C have a higher chance of SVR. In addition, patients who carry T/T (rs8099917) have a higher chance of RVR.

Transitional cell carcinoma of urinary bladder in a breast cancer survivor.

There is a propensity for the development of second malignancy in breast cancer patients either simultaneously with the first primary malignancy or after the control of the primary disease. The commonest sites to be involved with second malignancy in breast cancer patients are ovary, colon and endometrium. Other malignancies can also develop rarely either as a complication of treatment or de Novo. Here, a rare case is presented who developed transitional cell carcinoma of the urinary bladder 10 years after the treatment for breast cancer.

Epithelioid trophoblastic tumor: an unusual malignancy of ovary.

Epithelioid Trophoblastic Tumor (ETT) is a distinct but rare variety of gestational trophoblastic tumors. Misdiagnosis delays effective treatment and affects the survival. The case being reported here involved a 43 years old lady presented with 4 months history of intermenstrual per vaginal bleeding and 6 weeks amenorrhea. Workup has revealed pelvic mass. The patient underwent laparotomy with transabdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathology turned out to be clear cell carcinoma of the ovary. Patient was put on chemotherapy but there was progression of disease. Review of histopathology and immunohistochemistry revealed it as Epithelioid Trophoblastic Tumor; serum b-hCG was also raised. The case was really challenging for histopathologist. By the time final diagnosis was made, patient developed extensive metastases in lungs and liver and expired. Such an uncommon yet distinct trophoblastic tumor should be kept in mind by pathologists and treating physicians.

Adenocarcinoma of rectum as second primary cancer after treatment of endometrium cancer.

Colorectal cancer is the second leading cause of death from cancer in women in the United States. Previous epidemiologic studies have identified a 1.5 - 3 fold increased risk of colorectal cancer in women after ovarian and endometrial cancer. In Pakistan, neither such a study showing relationship of colorectal cancer with gynaecological cancer has been done nor any case has been reported. Here, a case is being reported who developed adenocarcinoma of rectum as the second primary about nine years after completion of treatment for adenocarcinoma of endometrium.

Molecular epidemiology of hepatitis C virus genotypes in different geographical regions of Punjab Province in Pakistan and a phylogenetic analysis.

BACKGROUND: Hepatitis C virus (HCV) is a causative agent of chronic liver disease, cirrhosis, and hepatocellular carcinoma. In Pakistan, more than 10 million people are living with HCV. Very little is known about the genotype distribution in Punjab Province, the largest province of Pakistan. Pretreatment genotype identification is very important, as different HCV genotypes respond differently to interferon therapy. METHODS: In this study we performed HCV genotyping for 1537 HCV-infected patients from different districts of Punjab Province, Pakistan. Sequencing of partial HCV NS5B sequences from 14 samples belonging to genotypes 3 and 1 was also done. A sequence comparison was made of our reported sequences with those reported in the National Center for Biotechnology Information (NCBI), and a phylogenetic tree was constructed. RESULTS: Our study showed that the most frequent HCV genotype was 3a (in 88.1% of infected individuals), followed by 1a (3.5%), 3b (3.0%), 1b (0.8%), and 2a (1.0%). A mixed genotype infection was found in 3.6% of infected individuals, with 0.3% living with 1a + 1b co-infection, 3.1% with 3a+3b, and 0.2% suffering from 3a+1b co-infection. The sequence comparison showed that HCV NS5B motif B residues G283, T287, and N291 were highly conserved in both genotype 1 and genotype 3 sequences, while the motif B residue T286 was mutated to proline in all the genotype 3 sequences. The GDD motif, which forms the catalytic pocket and binding site for the divalent cations, was highly conserved in all the reported sequences. The phylogenetic tree suggests clustering of genotype 1 sequences with sequences from the USA, UK, Germany, and France, while genotype 3 sequences are clustered with sequences from Japan and the UK. CONCLUSIONS: The major prevalent genotype in Punjab Province of Pakistan was genotype 3a, followed by genotype 1a, and only 3.6% of infected individuals had a mixed genotype infection. Sequencing of the HCV NS5B gene suggested that the active site residues were highly conserved in all the reported sequences. Our sequences, which are clustered with sequences from the USA, UK, France, and Japan, show the diversity in origin of the different genotypes prevalent in Pakistan.

Estrogen receptor, progesterone receptor, and Her 2 Neu positivity and its association with tumour characteristics and menopausal status in a breast cancer cohort from northern Pakistan.

OBJECTIVES: To measure the frequency of estrogen receptor (ER), progesterone receptor (PR), and Her 2 Neu positivity and to study their association with tumour characteristics and menopausal status in a breast cancer cohort from Northern Pakistan. METHODOLOGY: Patients attending NORI with histopathologically proven diagnosis of invasive ductal carcinoma of the breast were included after providing informed consent. Age, menopausal status, and tumour size were recorded. The presence or absence of nodal involvement (including site and number), distant metastases, sites of metastases, skin involvement, chest wall involvement, recurrent disease, and bilateral breast cancer were noted along with ER, PR, and Her 2 Neu status. Mean ± standard deviations were calculated for continuous variables like age. Frequency and percentage were calculated for categorical variables like ER, PR, and Her 2 Neu status. Association of ER, PR, and Her 2 Neu status with menopausal status and tumour-related characteristics were sought employing t test, x(2 )square test, and ANOVA wherever appropriate. P value >0.05 was considered significant. RESULTS: There were 1226 patients included in the study. Mean patient age was 48.04 ± 11.97 years, and 743 (60.6%) patients were premenopausal. ER, PR, and Her 2 Neu were found positive in 763 (62.2%), 738 (60.1%), and 478 (38.9%) patients, respectively. Significant association (P < 0.05) was found between ER, PR positivity, and Her 2 Neu over expression with menopausal status, tumour size, involvement of skin, chest wall and lymph nodes and the presence of distant metastases. However, no significant association was detected between ER, PR, Her 2 Neu and recurrent disease. CONCLUSIONS: The frequency of expression of hormonal receptors in breast cancer patients from Northern Pakistan is the same as reported in the literature although overexpression of Her 2 Neu is a little higher in our population. There is an inverse relationship between hormonal receptors expression and Her 2 Neu expression. Postmenopausal women have a higher incidence of ER and PR positivity and Her 2 Neu negativity. ER and PR negativity and Her 2 Neu positivity are associated with more advanced disease and poor outcome.

Polyostotic Paget's disease.

Paget's disease of bone is a common metabolic bone disease in most of the European countries. The disease has distinct geographical distribution being rare in Asia. We report Paget's disease in a 70 years old Pakistani male who presented with history of pain in right leg with difficulty in walking for the last 5 months. Plain X-ray raised suspicion of Paget's disease of bone. Technetium-99m MDP bone scan showed involvement of multiple bones. Bone biopsy confirmed the diagnosis. This case illustrates that Paget's disease of bone does exist in Pakistan.

Predictors of response to antiviral therapy in patients with chronic hepatitis C from Pakistani population.

BACKGROUND: Hepatitis C virus (HCV) constitutes a major public health issue around the world, especially in developing countries like Pakistan. In this study, we assessed outcome of interferon (INF) treatment in chronic hepatitis C patients categorized by gender, age, and viral load. METHODS: In this study, 750 HCV positive patients with genotype 3 were selected, out of which 616 completed the entire treatment. Their personal history, pre-treatment HCV RNA and serum alanine transaminase (ALT) was quantified. Patients were treated with combination therapy of INF-α 2b three million units (thrice a week) plus ribavirin (1000 - 1200 mg per day) for 24 weeks. After 24 weeks their HCV RNA and serum ALT level was quantified. RESULTS: Out of the 616 patients, 391 (63.5%) responded to therapeutic regimen (INF-α 2b plus ribavirin). Among the responders, 27.1% were men and 36.4% were women. Best treatment response was observed in patients having low viral load < 8 × 10(5) IU/ml and age ≤ 40 years than patients having low viral load and age > 40 years (73.2% vs. 60.3%, P = 0.05). CONCLUSIONS: Better response to IFN-α 2b plus ribavirin was observed in patients with lower viral RNA and younger age. It suggests that all patients considered for treatment should have quantification of serum HCV RNA level. The result can be used to counsel patients on the likelihood of response and may influence the patient's decision on treatment.