Management of patients with high-risk and advanced prostate cancer in the Middle East: resource-stratified consensus recommendations.

PURPOSE: Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. METHODS: The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. RESULTS: Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. CONCLUSION: This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources.

Case series of rhomboid ligament degeneration, mimicking a supraclavicular adenopathy.

A case series of 3 different patients showing very rare costoclavicular ligament increased SUV uptake on PET\CT with history of different types of cancer. This finding has not been described before especially that it corresponds to benign degenerative rather than sinister process. This is supported by low SUV and stability over months of follow up. Furthermore, even in degenerative joint diseases we have found very rare cases of such uptake. Experienced radiologists need to be always involved in the multidisciplinary team approach and be very cautious when approaching such findings to avoid any unnecessary medical interventions.

Psoas muscle sequestered disc mimicking an intramuscular abscess: A rare case report.

This report documents a rare case of a sequestered disc in the psoas muscle mimicking an intramuscular abscess, notable for its lack of systemic infection indicators and resolution without surgical intervention. Such cases emphasize the need for accurate differential diagnosis and highlight potential conservative management pathways for sequestered disc herniations. A 57-year-old male presented with acute low back pain following minor weight lifting, unresponsive to NSAIDs. MRI and CT imaging, followed by CT-guided aspiration and cultures, were employed to investigate a nodular structure within the right psoas muscle. Initial imaging suggested an infectious etiology; however, aspiration yielded no material, and cultures were negative. Follow-up MRIs demonstrated improvement and eventual resolution of the lesion, supporting a diagnosis of sequestered disc herniation. This case underscores the importance of considering differential diagnoses for psoas abscess-like presentations and suggests that conservative management may be sufficient in certain cases of sequestered disc fragments.

Migrating foreign material mimicking metastatic soft tissue sarcoma in a patient with history of synthol injection.

Injecting substances like Synthol for cosmetic muscle enhancement is known, but its potential for causing severe systemic complications is less documented. This case highlights the risks of foreign material migration, initially presenting as a suspected malignancy. A 47-year-old male presented with dyspnea and bilateral diffuse airspace opacities on chest X-ray, initially raising suspicions for metastatic disease. The patient's medical history was unremarkable until further detailed questioning revealed the use of Synthol injections. Initial imaging suggested metastatic soft tissue sarcoma with bilateral lung and various soft tissue masses detected on PET-CT scans. However, subsequent detailed examinations, including a CT-guided biopsy of the lung lesions, revealed no evidence of malignancy but instead chronic inflammation and fibrosis indicative of a reaction to foreign material. This finding prompted a re-evaluation of the initial diagnosis, leading to the identification of Synthol migration as the underlying cause of the patient's symptoms. This case underscores the importance of considering foreign substance migration in the differential diagnosis for patients presenting with unexplained tissue masses and emphasizes the need for thorough history-taking in elucidating the etiology of atypical radiologic findings. Early detection and accurate diagnosis can prevent unnecessary invasive procedures and facilitate appropriate management.

Ramsay Hunt Syndrome in Asymptomatic COVID-19 Infection: A Case Report and a Literature Review.

(1) Background: COVID-19 infection has affected almost 6 million people worldwide. Geniculate Ganglion Zoster resulting in Ramsay Hunt Syndrome (RHS) has been rarely described in this context. (2) Methods: Here, a case of RHS in the context of asymptomatic COVID-19 infection is reported followed by a literature review of the previously published cases (PubMed research combining "COVID-19" and "Ramsay Hunt Syndrome" or their abbreviations/synonyms, searching for data published at any time till October 2023). (3) Results: Five cases have been previously published (age range: 25-67 years; n = 3 males). Three patients were known to be immunocompetent prior to infection, one was receiving corticotherapy for lung disease, and one had an unspecified immune status. RHS predominantly involved both facial and vestibulocochlear nerves, with one case exclusively involving the facial nerve as the presented case. Regarding facial nerve palsy, three were right-sided (like the current report) and two were left-sided. Two cases were asymptomatic to COVID-19 (like the present patient), one had mild fatigue, and two had classical COVID-19 symptoms preceding RHS symptoms. Workup included serological testing against Varicella Zoster Virus and PCR assays that can detect the viral DNA in saliva, blood, tears, exudates, and cerebrospinal fluid. The treatment combined antiviral and corticosteroid therapies which yielded heterogeneous outcomes that might be related to some demographic and clinical data. (4) Conclusions: RHS rarely occurs in the context of COVID-19. Early recognition is important. Management seems to be similar to the classical condition. Some data may help predict facial nerve recovery.

Atypical choroid plexus papilloma treated with single agent bevacizumab.

Choroid plexus papillomas (CPPs) are usually not malignant and occur in less than 1% of brain tumors in patients of all ages. They represent 3% of childhood intracranial neoplasms with a predilection in younger ages. Papillomas have an indolent course and carry a good long-term outcome if gross total surgical resection is achieved. However malignant evolution may occur, with a 10-30% incidence. Chemotherapy has been used with varied degrees of success. Most series are very small, some are only limited to case reports and cannot lead to guidelines or therapeutic recommendations. We are reporting the first case of recurrent CPP treated with 5 mg/kg of bevacizumab administered once every two weeks. Complete patient evaluations with follow-up contrast-enhanced magnetic resonance imaging (MRI) scans were obtained after the initial two treatments and every 8 weeks thereafter. Only after two treatments, the MRI scans showed radiological stabilization of the tumor, and the patient achieved an excellent clinical response with significant resolution of all skin lesions.