City tumour board Karachi: an innovative step in multidisciplinary consensus meeting and its two years audit.

Management of cancer patients is a team work which usually comprises of surgeons, oncologists, radiologists, pathologists, psychiatrist, nutritionist and a nurse. Any patient who is suffering from any tumour needs a multimodality meeting as cancer treatment is not a single persons job. Most of the time, it is difficult to get the whole team together for a plan discussion due to their busy schedule. This problem was overcome by starting a tumour board meeting early morning of Sunday in Karachi which was named "City Tumour Board (CTB) Karachi". Its first meeting was held on Sunday March 28, 2010 and since then it takes place regularly fortnightly. Till March 2012, 44 sessions were conducted and total 264 cases were discussed. Here we present an audit of these two years. On average, in 60% of cases, tumour was up (36%) or down staged (12%) while in 52% of cases the stage remained unchanged. In 70% of cases (inclusive of above 60%), initial treatment plan was changed after discussion in the tumour board. This data signifies the importance of tumour board especially in a Pakistani setup where patient and even referring persons are not well aware of this disease and its outcome. It is advisable that every case should be discussed in tumour board before embarking on any treatment so that the best treatment plan can be given. It is also important that all relevant specialists should be present in the tumour board when planning for any treatment.

Prognostic sub-grouping of diffuse large B-cell lymphomas into germinal centre and post germinal centre groups by immunohistochemistry after 6 cycles of chemotherapy.

INTRODUCTION: Diffuse large B-cell lymphomas (DLBCL) can be divided into germinal centre (GC-DLBCL) and post germinal centre (post GC-DLBCL) groups by applying immunohistochemical antibodies. As these subgroups respond differently to chemotherapy, it is possible at diagnosis to select a poor prognostic subgroup for aggressive treatment. OBJECTIVE: To determine the frequencies of GC-DLBCL and post GC-DLBCL in patients by immunohistochemistry (IHC) and the clinical response after six cycles of chemotherapy. SUBJECTS AND METHODS: In this descriptive study conducted in AFIP and CMH, Rawalpindi and NORI, Islamabad, from September 2010 to September 2011, a total of 75 pretreatment cases of DLBCL diagnosed during the study period were included. Cases were segregated in to GC-DLBCL and post GC-DLBCL groups according to results of immunohistochemistry markers CD10, BCL6 and MUM1. Immediate clinical response was assessed after 6 cycles of chemotherapy. Response was divided into complete response, partial response, stable disease or relapse or progression. RESULTS: The mean age was 54.2 ± 15. Males were 53 (70.7%). Forty (53.3%) cases comprised the GC-DLBCL group; 25(62.5%) of them showed a complete response. Most patients of the post GC-DLBCL 19(54%) showed relapse/progression. Results of immediate clinical response in both prognostic subgroups were significant (p<0.05). Results regarding positivity with immunohistochemical antibodies CD10 (p 0.011), BCL6 (p 0.013) and MUM1 (p 0.000) regarding immediate clinical response were also significant. CONCLUSION: GC-DLBCL group shows better response to CHOP chemotherapy regimen. Immunohistochemistry should be used to further classify DLBCL as this can enable us to select aggressive group for aggressive treatment. This manuscript is important because the study is the first to becarried out exclusively in Pakistan or our part of the world.

Gliosarcoma: a rare variant of glioblastoma multiforme.

Gliosarcoma is a rare variant of Glioblastoma Multiforme (GBM). It is a very aggressive tumour and usually managed like GBM. Treatment of choice is surgery with good surgical margins followed by radiotherapy (60 Gy). Median survival is seven months. Here we present a case report of 55 years old male who was diagnosed as brain tumour in left temporoparietal region. It turned out to be gliosarcoma after surgical resection and histopathological evaluation.

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.

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.

Correlation of perfusion and contractility of left ventricle myocardium on gated myocardial perfusion scintigraphy.

BACKGROUND: Gated Single Photon Emission Computerized Tomography (SPECT) is a modality which is helpful in the detection of wall motion, thickening and ejection fraction of left ventricle. The purpose of this study was to correlate the ungated and gated SPECT in evaluation of left ventricle dysfunction. METHOD: It was a prospective study done at Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, in 2001/02. 76 patients (47 male and 29 female) with an average age of 52+/-11 years were inducted in this study. All patients underwent two days stress-rest Tc-99m MIBI (Methoxy Isobutyl Isonitrile) gated SPECT scan where 1110 MBq (30 mCi) was injected intravenously. Eight frames gating technique (variable fixed temporal resolution) of ECG was used to gate the cardiac cycle and whole acquisition was completed in 30 minutes. RESULTS: This technique very well evaluated the perfusion as well as wall motion/thickening (W/M/T) status of left ventricle. Out of 76 scans, 30% were normal, 22% transmural infarct, 25% partial thickness infarct, and 22% reversible ischemia. By doing the 20 segmental analyses, total 1520 segments were analyzed that revealed good concordance of perfusion with W/M/T in 78% of segments while 22% segments showed poor concordance. Out of these 22%, 12% were having more wall motion abnormalities than that of perfusion, while in 10%, it was vise versa. CONCLUSION: Results of this study shows good correlation between gated and ungated SPECT for evaluation of left ventricle dysfunction (r = 0.73, p< or =0.01).