The perception of burnout and related influencing factors in Tunisian oncology nurses.

BACKGROUND: Oncology nurses constantly provide emotional support to patients and are confronted with their suffering, which represents chronic stress leading to the development of burnout syndrome. AIM: This study aimed to evaluate the prevalence of burnout and identify associated factors in a sample of oncology nurses. METHODS: We conducted a descriptive cross-sectional study with 70 oncology nurses at the Salah Azaiez Institute of Oncology in Tunisia. Burnout was assessed using the Maslach Burnout Inventory Human Service Survey. This study follows the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Guidelines. RESULTS: Burnout affected 60 nurses (85.7%), with a high level in 20% of cases. High scores of emotional exhaustion, depersonalisation, and low personal accomplishment were recorded in 65.7%, 50% and 25.7% respectively. Emotional exhaustion was associated with higher age, marital status, having 2 or 3 or more dependent children, number of patients under care exceeding 15, professional experience and history of psychiatric problems. Depersonalisation was correlated with age, marital status, professional grade and history of psychiatric problems. Low levels of personal accomplishment increased with the number of patients under care, history of psychiatric problems and the regret of professional choice. CONCLUSION: Burn-out is a reality in oncology hospital with an alarming rate. Interventions including rationalisation of workload, support groups, training in emotion and stress management would improve the mental health of these nurses and increase their performance. The screening for burnout should be included as a regular practice in health promotion programmes for oncology health professionals, particularly for a vulnerable subgroup that possesses the risk mentioned above factors.

An isolated vaginal metastasis from rectal cancer: a case report.

INTRODUCTION: Vaginal metastasis from colorectal cancer is a rare occurrence, typically associated with other metastatic lesions. Isolated metastasis is exceedingly uncommon, with only a few cases documented in the literature. Vaginal involvement in colorectal cancer primarily results from direct contiguous spread from the primary tumor. CASE PRESENTATION: We present the case of a 70-year-old African woman diagnosed with adenocarcinoma of the middle rectum. She underwent chemotherapy, radiotherapy, and subsequent anterior resection. After 2 months, an isolated metastasis of rectal cancer was identified in the lower third of the left vaginal wall, confirmed by biopsy. Colonoscopy ruled out colorectal recurrence. Thoraco-abdominal computed tomography scan showed no distant metastases. The patient underwent abdominoperineal resection, removing the lateral and posterior vaginal wall with free macroscopic margins and a definitive colostomy. The final histopathological analysis confirmed the diagnosis of moderately differentiated adenocarcinoma of the vagina, measuring 5 × 4.5 cm. The rectal wall was extrinsically invaded by the tumor down to the muscularis propria while respecting the rectal mucosa. Resection margins were negative. The patient was discharged 1 week postoperation with no complications. Adjuvant chemotherapy was indicated, and the patient is currently tolerating the treatment well. CONCLUSION: Vaginal metastases from colorectal cancer are extremely rare. A vigilant gynecological examination is recommended during the follow-up of colorectal cancer patients. Diagnosis can be challenging, especially if the metastatic lesion is small and asymptomatic, even after standard radiological examination. Surgical resection followed by chemotherapy is a valid option for patients with early isolated metastases.

Primary cutaneous apocrine carcinoma: A challenging case report.

INTRODUCTION: Primary cutaneous apocrine carcinomas of the axilla represents an extremely rare entity, with <200 cases reported in the literature. It can be challenging, even almost impossible, to distinguish histologically from metastases of breast origin. We herein present the first case of an axillary cutaneous apocrine adenocarcinoma followed and treated in our institute. CASE PRESENTATION: A 58-year-old man with a history of myopathy, presented for a right axillary swelling. Physical examination revealed the presence of a 10 cm right axillary mass, no palpable adenopathy, and bilateral gynecomastia. A biopsy of the mass was performed, showing a pattern consistent with a secondary localization of mammary neoplasia. Breast and distant radiological examinations were negative. The tumor markers' levels were not raised. Therefore, the patient underwent surgery with a large excision, a right axillary lymph node dissection, covered with a pedicled pectoralis major flap. Histological and immunohistochemical examinations showed a high expression of CK7 with a negative expression of TTF1, RH, PSA, and CK20. The diagnosis of an apocrine adenocarcinoma from cutaneous origin was confirmed. CLINICAL DISCUSSION: Primary cutaneous apocrine carcinomas are a group of uncommon malignant adnexal tumors, whose diagnosis is almost impossible to confirm preoperatively. Wide, local excision with clear margins, with or without lymph node dissection is the standard treatment. CONCLUSION: This case illustrates the importance of clinico-pathological correlation of skin cancers, especially apocrine ones. Clinical particularity and careful histological analysis are used to guide the diagnostic approach.

Primary thyroid lymphoma: a case series.

INTRODUCTION: Primary Thyroid Lymphoma (PTL) is defined as lymphoma involving the thyroid gland alone or the thyroid gland and adjacent neck lymph nodes without contiguous spread or distant metastases at the time of diagnosis. Most thyroid lymphomas are B cell lymphomas, and 98% of all PTL cases are non-Hodgkin's lymphoma. It is a rare disease accounting for around 5% of the thyroid neoplasms and 2% of extranodal lymphomas. If properly diagnosed and treated, the prognosis is favorable. CASE PRESENTATION: Five cases (three men and two women) of PTL were diagnosed and treated in our institute between January 2005 and September 2019. These are 5 cases of Caucasian origin. The mean age was 76.2 (range: 63-95 years); one patient had associated hypothyroid. One patient had a medical history of breast cancer; one was hypothyroid, and four were euthyroid at the diagnosis. In 4 of these patients, PTL started with compressive symptoms. No patients underwent fine needle aspiration cytology (FNAC) or biopsy for the diagnostic only. In sonography, two cases showed bilateral nodules with goiter; in the three cases it showed nodules in the lobe and isthmus. Technetium-99m scintigraphy was performed on only two patients. Bone Marrow Biopsy (BMB) showed normal cellularity in 4 cases and only one case showed tumor cells. LDH levels were increased in all cases. The extension was evaluated in all patients with cervical and thoracic CT scans, Bone Marrow Biopsy (BMB), beta-2 microglobulin, and serum lactate dehydrogenase (LDH) levels. Three cases were staged as IE and two cases as IIE. Three patients underwent total thyroidectomy; two of them underwent cervical lymph node dissection. Two patients underwent lobectomy. All were diagnosed with lymphoma postoperatively and all were diffuse large B cell lymphoma (DLBCL). One patient completed treatment with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone), and two cases received adjuvant chemo-radiotherapy (30 Gy). Two patients died immediately after surgery. CONCLUSION: PTL is a rare disease whose diagnosis should be considered in cases of rapidly growing goitres. Timely needle biopsy in suspected cases can avoid unnecessary surgery. Systemic treatment is required, depending on the stage of the tumour.

Giant gluteal and vesical plexiform neurofibromas in a patient with neurofibromatosis type 1: a case report.

BACKGROUND: Neurofibromatosis type 1 is a neurocutaneous genetic disorder caused by mutations in the NF1 gene, resulting in the formation of benign tumors called neurofibromas. The most common type of tumor seen in patients with neurofibromatosis type 1 is the slow-growing and benign neurofibroma, with a subtype called plexiform neurofibroma being particularly common and causing pain, functional impairment, and cosmetic disfigurement. CASE PRESENTATION: We report the case of a 20-year-old North African female patient with a history of neurofibromatosis type 1 who presented with a growing mass in her right gluteal region, which was later diagnosed as a giant cutaneous neurofibroma. Imaging studies revealed infiltration in several regions, including the urinary bladder wall, resulting in significant bilateral hydronephrosis. The patient is currently being monitored, and no excisional procedures are planned. CONCLUSIONS: Neurofibromatosis type 1 can cause a variety of clinical symptoms, including the development of large plexiform neurofibromas. It is important to closely monitor patients with neurofibromatosis type 1 for the early detection of neurofibromas. Early detection and prompt surgical intervention are essential for preventing complications.

De novo male breast metastases from nasopharyngeal carcinoma: a case report.

BACKGROUND: Nasopharyngeal carcinoma is known for its high potential for regional and distant metastasis. However, breast metastasis is rarely reported. CASE PRESENTATION: A 39-year-old Caucasian male presented with bilateral neck lymph node enlargement. Radiological examination with contrast-enhanced computed tomography scan and breast imaging revealed an enhancing mass lesion in the right breast. Histopathology of the nasopharynx mass was suggestive of undifferentiated nasopharyngeal carcinoma. A breast biopsy confirmed the diagnosis of synchronous breast metastasis from the nasopharyngeal carcinoma. We present this study to illustrate that Nasopharyngeal carcinoma can metastasize to the male breast. Furthermore, the high incidence of nasopharyngeal carcinoma metastasis underscores the pressing need to identify effective and safe strategies, emphasizing the importance of utilizing computed tomography scans for metastasis detection. CONCLUSION: The present study illustrates the first case of synchronous male breast metastases from nasopharyngeal carcinoma. Thus, it is critical to distinguish between metastatic pathology and coexisting second malignancies to plan appropriate therapy.

Pseudo tumor pelvic actinomycosis revealed by colonic obstruction with hydronephrosis: Can extensive surgery be avoided? A case report.

Pelvic actinomycosis with an intrauterine device accounts for approximately 3% of all actinomycoses. It is a chronic infectious disease characterized by infiltrative, suppurative, or granulomatous inflammation, sinus fistula formation, and extensive fibrosis, and caused by filamentous, gram-positive, anaerobic bacteria called Actinomyces israelii. The slow and silent progression favors pseudo tumor pelvic extension and exposes the patient to acute life-threatening complications, namely colonic occlusion with hydronephrosis. Preoperative diagnosis is often difficult due to the absence of specific symptomatology and pathognomonic radiological signs simulating pelvic cancer. We discuss the case of a 67-year-old woman who complained of pelvic pain, constipation, and weight loss for 4 months, and who presented to the emergency department with a picture of colonic obstruction and a biological inflammatory syndrome. The computed tomography scan revealed a suspicious heterogeneous pelvic mass infiltrating the uterus with an intrauterine device, the sigmoid with extensive upstream colonic distension, and right hydronephrosis. The patient underwent emergency surgery with segmental colonic resection and temporary colostomy, followed by antibiotic therapy. The favorable clinical and radiological evolution under prolonged antibiotic therapy with the almost total disappearance of the pelvic pseudo tumor infiltration confirms the diagnosis of pelvic actinomycosis and thus makes it possible to avoid an extensive and mutilating surgery with important morbidity.

Cutaneous metastasis as a first presentation of lung carcinoma: a case series.

INTRODUCTION: Cutaneous metastases (CM) revealing lung carcinoma are extremely rare, accounting for 0.8%. The diagnosis is guided by histology and immunohistochemistry. Treatment is palliative. The prognosis is poor. CASE PRESENTATION: This is a retrospective study of the available clinical and histological records of four North African patients with CM revealing lung cancer treated at our institute between 2004 and 2010. Three men and one woman were registered. The mean age was 54.5 years (38-74 years). Two patients had primary adenocarcinoma, one patient had small cell carcinoma and one had squamous cell carcinoma. Treatment was based on chemotherapy in two cases and antalgic radiotherapy in two cases, one patient underwent surgical resection as the lesion was infected. The overall survival after diagnosis was between one and four months. CONCLUSIONS: A skin nodule can be the first symptom revealing lung cancer. A rare clinical presentation that should not be taken for a benign nodule, the biopsy and histological study with immunohistochemistry confirm the diagnosis.

A huge prolapsed cervical leiomyoma: A case report.

INTRODUCTION AND IMPORTANCE: Uterine leiomyoma is the most common pelvic tumor in women. Its cervical location is rare and may extend into the vagina in 2.5 % of cases. Treatment of cervical fibroids includes either myomectomy or hysterectomy, depending on the patient's profile and the tumor's characteristics. These fibroids challenge the surgeon because of their proximity to vital pelvic structures and their likelihood of causing surgical complications. CASE PRESENTATION: A 47-year-old woman presented with abdominopelvic pain and a bulky necrotic mass protruding out of her vagina. CT scan showed a large heterogeneous anterior mass of the cervix measuring 30 cm prolapsed in the vagina. She underwent a total hysterectomy with complete resection of the cervical mass. The histopathological report confirmed the diagnosis of a cervical leiomyoma with no signs of malignancy. CLINICAL DISCUSSION: Three types of cervical leiomyoma are known: interstitial, supra-vaginal, and polypoidal. The last one, observed in our case, is the rarest type. When prolapsed in the vagina, cervical leiomyoma can outgrow its blood supply and become necrotic. Several approaches are available for the management of cervical leiomyomas. The approach choice depends on many factors such as the tumor size and location, its extent, and the desire for fertility. CONCLUSION: This report describes the case of a large gangrenous and prolapsed non-pedunculated cervical leiomyoma which remains a rare and disabling complication of this benign tumor for which hysterectomy remains the treatment of choice.

Association of HLA-G 3'UTR polymorphisms and haplotypes with colorectal cancer susceptibility and prognosis.

Human leukocyte antigen (HLA)-G has been considered as an immune modulator in several types of cancers. Its genetic polymorphisms may potentially affect the risk of developing colorectal cancer (CRC). The overall purpose of this study was to analyze the implication of HLA-G 3'untranslated region (3'UTR) polymorphisms particularly 14 pb insertion/deletion (Ins/Del; rs371194629) and + 3142C/G (rs1063320) in CRC susceptibility and progression. A comparative analysis between patients (N = 233) and controls (N = 241) demonstrated that Del allele (Odds Ratios (OR) = 1.41, 95% CI = 1.091-1.819, p = 0.008), the homozygous Del/Del genotype (OR = 1.80, 95% CI = 1.205-2.664, p = 0.003) and the codominant C/G genotype (OR = 1.59, 95% CI = 1.106-2.272, p = 0.013) were associated to CRC risk. As expected, the DelG haplotype was associated with CRC susceptibility (OR = 1.47, 95% CI = 1.068-2.012, p = 0.018). Assessment of patients' survival by Kaplan-Meier analysis indicated that the Del allele and the homozygous Del/Del genotype were associated with reduced event free survival (EFS) (Respectively, p = 0.009 and p = 0.05). Interestingly, the Del allele and the homozygous Del/Del genotype have been revealed as independent prognostic factors for poor EFS in patients with CRC. Additionally, haplotypes analysis revealed that DelG haplotype was linked with significant increase in CRC risk (log-rank; EFS: p = 0.02). Inversely, the InsC haplotype was associated with a significant reduced CRC risk (log-rank; Overall survival (OS): p < 10-6; EFS: p = 0.01). Multivariate Cox regression analysis revealed that the InsC haplotype was independently associated with significantly longer EFS (p = 0.021, HR = 0.636, 95% CI = 0.433-0.935). These findings support the implication of HLA-G polymorphisms in the CRC susceptibility suggesting HLA-G as a potent prognostic and predictive indicator for CRC. Insight into mechanisms underlying HLA-G polymorphisms could allow for the development of targeted care for CRC patients according to their genetic profile.

Chemoradiotherapy or chemotherapy as adjuvant treatment for resected gastric cancer: should we use selection criteria?

BACKGROUND: The management of gastric adenocarcinoma is essentially based on surgery followed by adjuvant treatment. Adjuvant chemotherapy (CT) as well as chemoradiotherapy (CTRT) have proven their effectiveness in survival outcomes compared to surgery alone. However, there is little data comparing the two adjuvant approaches. This study aimed to compare the prognosis and survival outcomes of patients with gastric adenocarcinoma operated and treated by adjuvant radio-chemotherapy or chemotherapy. MATERIALS AND METHODS: We retrospectively evaluated 80 patients with locally advanced gastric cancer (LGC) who received adjuvant treatment. We compared survival outcomes and patterns of recurrence of 53 patients treated by CTRT and those of 27 patients treated by CT. RESULTS: After a median follow-up of 38.48 months, CTRT resulted in a significant improvement of the 5-year PFS (60.9% vs. 36%, p = 0.03) and the 5-year OS (55.9% vs. 33%, p = 0.015) compared to adjuvant CT. The 5-year OS was significantly increased by adjuvant CTRT (p = 0.046) in patients with lymph node metastasis, and particularly those with advanced pN stage (p = 0.0078) and high lymph node ratio (LNR) exceeding 25% (p = 0.012). Also, there was a significant improvement of the PFS of patients classified pN2-N3 (p = 0.022) with a high LNR (p = 0.018). CTRT was also associated with improved OS and PFS in patients with lymphovascular and perineural invasion (LVI and PNI) compared to chemotherapy. CONCLUSION: There is a particular survival benefit of adding radiotherapy to chemotherapy in patients with selected criteria such as lymph node involvement, high LNR LVI, and PNI.

Prognostic significance of high circulating sHLA-G in ovarian carcinoma.

HLA-G is a non-classical major histocompatibility complex class Ib molecule. Its expression has been described in various cancer types, including ovarian cancer. HLA-G molecule has been implicated in immune escape and in progression of ovarian tumor cells. Our goal was to assess if total soluble (s)HLA-G molecules or HLA-G5 and sHLA-G1 isoforms could be considered as circulating ovarian tumor biomarkers, we measured the concentration of these molecules in ovarian carcinoma patients stratified according with their clinicopathological parameters. sHLA-G, sHLA-G1 and HLA-G5 concentrations were dosed in plasma samples by sandwich-ELISA. The sHLA-G dimerization was analyzed after immunoprecipitation and SDS-PAGE migration. Total sHLA-G and sHLA-G1 levels were significantly represented in plasma of ovarian carcinoma patients compared to healthy controls. sHLA-G1 isoform concentration was highly represented in ovarian carcinoma compared to HLA-G5 isoforms. Additionally, high sHLA-G molecules have been found in aged patients, as well as in patients with advanced stages, and those with metastatic lymph nodes and those with distant metastasis. Elsewhere, sHLA-G monomers were highly represented in ovarian carcinoma patients compared to controls. sHLA-G plasmatic protein was highly represented in ovarian carcinoma. In effect, HLA-G might be considered as a new checkpoint molecule that could be used to assess progression and recurrence of the disease, thus placing it as a potential biomarker for advanced and complicated ovarian carcinoma.

Intraabdominal lesser sac metastasis from Ewing's sarcoma: An exceptional localization.

Ewing's sarcoma/primitive neuroectodermal tumor is rare and aggressive with a poor prognosis. Intraabdominal metastases are an uncommon condition. Metastasis in the lesser sac is an exceptional occurrence. To the best of our knowledge, this location has not been described previously. We report a case of a 15-year-old patient treated for Ewing's sarcoma of the left arm 6 years back. She had developed a suspicious mass in the lesser sac 6 years following her primary tumor. The histopathologic exam revealed a tumor with "small round cells" that were positive for CD99, confirming the relapse of Ewing's sarcoma. The relapse was successfully managed with chemotherapy and surgery. Intraabdominal, extraintestinal masses in patients treated previously for Ewing's sarcoma should be considered as Ewing's sarcoma relapse in the differential diagnosis. We fully describe the management of this atypical relapse, with different components of clinical, radiological, and histological findings.

Expression analysis of immune-regulatory molecules HLA-G, HLA-E and IDO in endometrial cancer.

HLA-G has been widely implicated in advanced cancers through different pathways of immunosuppression allowing tumor escape. Contrarily, HLA-E has a controversial role in the tumor escape from the immune system. IDO catabolic enzyme is known to be up-regulated in many tumors types allowing their immune escape. Based on these considerations, we investigated the expression of HLA-G, HLA-E and IDO molecules in endometrial cancer (EC) and their association with prognostic clinicopathologic parameters. Their expression were checked in tumoral and adjacent endometrial tissues. Both HLA-G and IDO immunostaining were significantly increased in EC tissues compared to normal residual endometrial glands (Mann Whitney U-test, p = 0.0001 and p = 0,020 respectively). However, HLA-E was highly expressed in tumoral tissues as well as in normal residual endometrial glands (respectively, 100% and 81.8%). Increased HLA-G expression levels were observed in high histological grade (grade 3), and in the non-endometrioid type 2 EC. Unexpectedly, patients with IDO Low expression had significantly impaired overall survival compared to patients with IDO High (log-rank p = 0.021). Conversely, HLA-E low expression was associated to an improved overall survival EC (log-rank p = 0.004). We concluded that, HLA-G and IDO are highly expressed in EC compared to adjacent normal endometrial tissues, that might be interesting for the EC outcome.

Coexistence of invasive ductal breast carcinoma and fibroadenoma.

Fibroadenomas are the most common breast disease that occurs usually in young. The coexistence of an invasive ductal carcinoma and a fibroadenoma in the ipsilateral breast is extremely rare. We present the case of a 52 years woman, presented to us for an upper-outer breast lump. Breast imaging concluded to tow contiguous lesions, one of them was suspicious. She had a conservative surgery. Histology concluded to a fibroadenoma and an invasive ductal carcinoma.

A Single Liver Metastasis From Adenoid Cystic Carcinoma of the Parotid Gland: Case Report.

Adenoid cystic carcinoma is an uncommon malignant neoplasm of the salivary gland. Liver metastasis from salivary gland cancer is a rare situation. In this article, we report the case of a 29-year-old woman treated 5 years previously for adenoid cystic carcinoma of the parotid gland by surgery and radiotherapy, who presented for a large hypervascularized hepatic metastasis of 20 cm. After 3-cycle chemotherapy stability, hepatic surgery was successfully performed. The patient maintained disease-free period of 12 months after the surgical treatment. This rare case represents a therapeutic challenge for oncologists and surgeons. Through this case and a review of the literature, we try to better detail the management of this uncommon entity.

Dermatofibrosarcoma Protuberans of the Breast in Man: An Extremely Rare Entity With a Review of the Literature.

Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma of soft tissue representing about 1% of all tumors. In addition, DFSP occurs commonly on the trunk and extremities, and only a few cases of DFSP have been observed on the breast. In men, only 11 cases, including this case, have been reported. In this article, we present a case of left breast DFSP that occurred in a 44-year-old man. The physical examination revealed a left breast tender mass, which invaded the skin. The tumor was staged as T4b N0 M0. Mammography and sonography showed a suspect mass of the left breast. The biopsy and immunochemistry permitted the diagnosis of DFSP of the left breast. The patient had a left mammectomy, with free margins. He presents no evident sign of recurrence 7 months later.

Vulvar Darier-Ferrand dermatofibrosarcoma: unusual localization of a rare tumor.

Dermatofibrosarcoma protuberans (DFSP) is a low-to-intermediate grade sarcoma of dermal origin that rarely presents in the vulva, typically occurring on the trunk of young to middle-aged adults. Even though it has a low potential for distant metastases, it often recurs locally. Therefore, surgical excision is the treatment of choice. We report a case of DFSP with fibrosarcoma transformation involving the vulva treated by large excision with tumor free margins followed by plastic reconstruction. Our aim is to highlight this rare disease and through literature evaluate the safety and efficacy of surgical treatment. Early recognition of this rare entity whose localization and the aggressive nature of the fibrosarcomatous component will be an issue in the surgical management.

HLA-G, HLA-E, and IDO overexpression predicts a worse survival of Tunisian patients with vulvar squamous cell carcinoma.

Little is known about non-classical HLA molecules in vulvar squamous cell carcinoma (VSCC). Because of the indoleamine-2,3-dioxygenase (IDO) immune tolerant role in association with HLA-G, we evaluated the clinical and prognostic value of HLA-G, HLA-E, and IDO in VSCC. HLA-G, HLA-E, and IDO expression was determined by immunohistochemistry in VSCC and associated with clinicopathological parameters and disease outcome. These three molecules were highly represented in tumoral tissues vs healthy matched vulvar tissues (P = 0.0001). Significant differences in HLA-G expression in stages, tumor size, tumor invasion depth, and resection margins subgroups were reported (P < 0.05). At 5 years, the cumulative survival rates was of 79.8% in patients with HLA-Glow expression vs 12.5% in those with HLA-Ghigh expression (P < 3 × 10-5 ). Similarly, patients with IDOhigh expression were at a significantly reduced overall survival (OS) and disease-free survival (DFS) rates (P = 0.011 and 0.045, respectively). The overexpression of the three molecules together worsen survival rates of VSCC patients (OS: P = 0.000038, DFS: P = 0.000085). Altogether, our results showed that HLA-G, HLA-E, and IDO may represent novel candidate markers for patients' prognosis and potential targets for VSCC therapy.