Integrating MDT Tumor Board Shadowing into the Undergraduate Medical Curriculum: Perspective of Medical Students.

Site-specific multidisciplinary team (MDT) tumor boards are valuable resources for medical students, enabling them to familiarize themselves with the latest evidence-based cancer management strategies and observe effective teamwork in action. In this study, we looked at the awareness and perceptions of medical students about incorporating MDT tumor boards in the medical curriculum. A cross-sectional study was conducted among medical students from year 1 to year 5 at the Aga Khan University after exemption from ethical review committee. A 20-item self-administered questionnaire was used to evaluate the awareness and perceptions of medical students regarding MDT tumor boards. A total of 285 medical students participated in this study, with their mean age (± standard deviation) being 21.91 ± 1.67 years. A majority of 183 (64.2%) had no prior knowledge of the existence of a site-specific MDT tumor board for cancer management. Of the 285 students, 252 (88.4%) demonstrated sufficient awareness of the effectiveness of MDT tumor boards; similarly, 232 (81.4%) responded positively to the idea of mandatory tumor board rotations being incorporated into the undergraduate curriculum. No significant association was found between the student's year of study (χ2 = 6.03, p = 0.20) or gender (χ2 = 35, p = 0.84) and their perceptions of the effectiveness of MDT tumor boards. However, it was found that students who had prior knowledge of their existence had a stronger association with sufficient awareness (χ2 = 4.2, p = 0.04). The results indicate that while the majority of the medical students have no prior attendance or knowledge regarding MDT tumor boards, there is an overwhelming willingness among students to incorporate them into the medical curriculum.

Building the ecosystem for pediatric neuro-oncology care in Pakistan: Results of a 7-year long twinning program between Canada and Pakistan.

BACKGROUND: Low- and middle-income countries sustain the majority of pediatric cancer burden, with significantly poorer survival rates compared to high-income countries. Collaboration between institutions in low- and middle-income countries and high-income countries is one of the ways to improve cancer outcomes. METHODS: Patient characteristics and effects of a pediatric neuro-oncology twinning program between the Hospital for Sick Children in Toronto, Canada and several hospitals in Karachi, Pakistan over 7 years are described in this article. RESULTS: A total of 460 patients were included in the study. The most common primary central nervous system tumors were low-grade gliomas (26.7%), followed by medulloblastomas (18%), high-grade gliomas (15%), ependymomas (11%), and craniopharyngiomas (11.7%). Changes to the proposed management plans were made in consultation with expert physicians from the Hospital for Sick Children in Toronto, Canada. On average, 24% of the discussed cases required a change in the original management plan over the course of the twinning program. However, a decreasing trend in change in management plans was observed, from 36% during the first 3.5 years to 16% in the last 3 years. This program also led to the launch of a national pediatric neuro-oncology telemedicine program in Pakistan. CONCLUSIONS: Multidisciplinary and collaborative efforts by experts from across the world have aided in the correct diagnosis and treatment of children with brain tumors and helped establish local treatment protocols. This experience may be a model for other low- and middle-income countries that are planning on creating similar programs.

Total skin electron beam therapy (TSEBT) in management of mycosis fungoides: A case series.

A retrospective review was conducted In Aga Khan University from January 2013-December 2020 for patients who received Total Skin Electron Beam Therapy (TSEBT) on the management of Mycosis Fungoides (MF). The clinical response rate and disease-free interval (DFI) was evaluated for three patients. All of the patients received a 3600 cGy dose of radiation. Clinical complete remission (cCR) was observed in two out of three patients, while one patient showed clinical partial response. Following the cCR to TSEBT, the DFI of the first patient with stage 1B lasted 30 months, while the second patient with stage IIB remained disease free for five months. TSEBT is an effective treatment for MF disease. It can thus be expected that patients with limited disease in the early stage can acquire a cCR with a longer DFI. The clinical outcomes of our study show concordance with the literature. The patients who had extensive (T3) skin involvement and had refractory diseases showed lower DFI with radiation.

Solitary rib metastasis from primary nasopharyngeal carcinoma: A rare clinical presentation.

We report a case of a middle age male who presented to our tertiary care university hospital with the complaints of nasal obstruction and decrease hearing. The CT scan of head and neck exhibited a mass in nasopharynx and enlarged bilateral cervical lymph nodes. Biopsy from nasopharynx confirmed the lesion as poorly differentiated non-keratinizing squamous cell carcinoma and staged as cT2N2M0. He received neoadjuvant chemotherapy. Subsequently, he underwent chemo radiation therapy. He represented with left chest wall pain. Imaging confirmed isolated lesion on left sided 6th rib. Rib lesion was resected followed by radiation therapy to surgical bed and systemic treatment. The patient remained disease free for 4.5 years. Later, his disease relapsed, and he died of systemic disease progression. To the best of the author's knowledge, only few cases have been reported with isolated rib metastasis from nasopharyngeal carcinoma and this is the first case in which metastasectomy was considered.

Recent updates in the management of Merkel Cell Carcinoma.

Merkel cell carcinoma is an aggressive non-melanomatous cutaneous tumour of neuroendocrine origin with an increasing incidence in the recent years. It is a tumour of the elderly and immunosuppressed, which most often appears on sun-exposed areas of the body. The clinical features of the cutaneous or subcutaneous lesions hardly contribute to the diagnosis, and, hence, histopathology and immunohistochemistry play a vital role in diagnosis. The latest staging system by the American Joint Committee on Cancer includes non-nodal invasion to adjacent structures i.e. bone, muscle, fascia, or cartilage into the criteria, in additionto size and depth of invasion. The management reliesheavily on a multidisciplinary approach due to rarity of incidence of this disease. According to the international guidelines, surgical management is still the preferred choice. The beneficial role of adjuvant radiotherapy has now been more clearly documented. Data is insufficient to assess whether chemotherapy improves disease-free or overall survival.

Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP).

Pediatric radiotherapy is a critical part of pediatric oncology protocols and the quality of the radiotherapy may determine the future quality of life for long-term survivors. Multidisciplinary team decision making provides the basis for high-quality care. However, delivery of high-quality radiotherapy is dependent on resources. This article provides guidelines for delivery of good quality radiation therapy in resource-limited countries based on rational procurement and maintenance planning, protocol development, three-dimensional planning, quality assurance, and adequate staff numbers and training.

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.

Rationale of Establishment of Cardio-oncology Multi- disciplinary Team Tumour Boards in Pakistan.

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Importance of Development of Rare Cancers National Tumour Board.

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Emotional Intelligence Training can be Incorporated as an Essential Component of Postgraduate Medical Education: Paving the Way Towards the Development of Multidisciplinary Team Culture.

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A Step towards Personalised Cancer Treatment in Lower Middle-income Countries (LMICS): Molecular Tumour Boards.

Tumour boards are meetings where physicians from various disciplines treating cancer patients meet to recommend evidence-based or the best possible treatment plan. These meetings have evolved with time and now, in every part of the world; site-specific multi-disciplinary tumour boards are established. These meetings are considered pivotal for improving patient outcomes. The advances in molecular and genetic knowledge and technique and their integration in treatment options have paved the way for multiple therapeutic options. However, the adoption of personalised treatment choices is associated with a huge financial burden, especially in low and middle-income countries (LMICs). A molecular tumour board can help to identify and suggest the most appropriate plan of management. Key Words: Molecular, Genetics, Personalised, Challenges.

Acute Oral Mucositis During Hypo-Fractionated Radiation in Squamous Cell Carcinoma of Oral Cavity.

Oral mucositis remains a concern in the treatment of head and neck malignancies. This small study included 11 patients treated by hypo-fractionated radiotherapy and assessed for oral mucositis. All patients received a radiation dose of 55 Gy in 20 fractions (2.75 Gy/fraction). At the end of the first week of radiation, three patients had Grade I oral mucositis. During the last week of radiation, most of the patients developed Grade II and III mucositis, 7 (64%) and 4 (36%), respectively. At one month follow-up, 5 (46%) of them had Grade I, while 2 (18%) had developed Grade II mucositis. At three months, 2 (18%) had Grade I mucositis, and none of the patients showed Grade II/III oral mucositis. Grade II oral mucositis was the most common grade found mainly in the last week of radiation therapy. None had Grade IV oral mucositis. Key Words: Acute oral mucositis, Hypo-fractioned radiation, Oral carcinoma.

Outcomes Of Reconstruction With Vascularized Vs Non Vascularized Bone Graft After Resection Of Bone Tumours- A Systematic Review And Meta-Analysis.

BACKGROUND: Vascularized (VBG) and non-vascularized (NVBG) bone grafting are two crucial biological reconstructive techniques in the management of bone tumours. The objective of this study is to compare the outcomes of reconstruction with vascularized and non-vascularized bone grafts after resection of bone tumours. METHODS: A systematic evaluation of the literature from 2012-2021 was undertaken using the online databases PubMed/Medline, Google Scholar, and Cochrane Library considering only comparative articles with specific outcomes for the restoration of the defect with vascularized and non-vascularized bone graft following the resection of bone tumours. The quality of the research methodology was evaluated using Oxford Quality Scoring System and Newcastle Ottawa Scale for randomized trials and non-randomized comparison research respectively. The SPSS version 23 was used to examine the data that was collected. Musculoskeletal tumour society score (MSTS), bone union time, and complications were the outcomes of this review. RESULTS: Four clinical publications were considered, totalling 178 participants (92 men and 86 women) with 90 patients with VBG and 88 with NVBG. MSTS score and bone union time were the key outcomes that were measured. The overall MSTS (p>0.05) and rate of complications (p>0.05) results were comparable between the two groups, however, VBG had a better rate of bone union (p<0.001). CONCLUSIONS: As a result of the quicker bone union, our systematic evaluation demonstrated that VBG causes earlier recovery. Complication rates and functional results were the same in both groups. The link between the bone union time and functional score following VBG and NVBG must also be demonstrated.

Latest update on the clinical features and management of Merkel cell carcinoma.

Merkel cell carcinoma (MCC), is a rare, highly malignant skin tumour, with a poor prognosis. Though the aetiology of MCC is not known, but there are several features that it shares with melanoma. These include the natural history, clinical features and behaviour, e.g. an early spread to nodal sites, high local recurrence rate and early metastasis. Incidence of MCC is seen to be increased in immunosuppressed transplant patients, in patients with rheumatoid arthritis and in B cell malignancies, with a strong male predominance. Despite the ongoing research and advancement, MCC yet poses a challenge to the clinicians because of its rarity. The purpose of this paper is to review the most salient and clinically relevant updates of MCC since its first publication in July 2007 in JPMA. In order to expedite an improved understanding of the new diagnostic modalities, treatment and preventive measures, along with the new staging system established in 2009 after an extensive literature review, and an analysis of over 5,000 patients using the National Cancer Database has all been included in our article.

FIGO IVB (para-aortic lymph adenopathy) squamous cell carcinoma of uterine cervix associated with a left pelvic kidney: a therapeutic challenge.

The standard of care for locally advanced carcinoma of uterine cervix is concurrent chemoradiation therapy followed by intracavitary brachytherapy, when there is para-aortic lymphadenopathy, radiation field needs to be extended to para-aortic region. In the latter case dose limiting organs are spinal cord, kidneys and small intestine. We present a challenging case of FIGO IVB squamous cell carcinoma of cervix and a pelvic kidney. This patient received chemoradiation to pelvis and para-aortic field, brachytherapy was not performed as patient already had undergone attempted hysterectomy. Treatment, outcome and challenges encountered in this case are presented and literature is reviewed.

Financial Toxicity Tumor Board: A Multi-disciplinary Team Activity Required in Low and Middle-income Countries (LMIC).

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Outcomes Of Intraoperative Radiotherapy (Iort) For Spinal Tumours.

BACKGROUND: The spinal column is a major site of neoplastic proliferation where decisions regarding surgical or radiotherapeutic intervention are based upon spinal instability neoplastic score (SINS). A novel technique named 'Intraoperative radiotherapy (IORT) was proposed where surgery and radiotherapy were performed in the same session. During our literature search, we found no published systematic review or meta-analysis regarding the outcomes of IORT for spinal tumors. This review aims to provide the knowledge regarding the outcomes of IORT for spinal tumors to assist surgeons and radiologists. METHODS: PubMed, Google Scholar, Cochrane library for trials reporting the outcomes of IORTin spinal tumors. The search terms were "outcomes", "Intraoperative radiotherapy", "IORT", "spine neoplasia" and "spine metastasis" in different combinations. Standardized mean difference (SMD) in VAS for pain relief while proportionality for neurological improvement, local progression, and toxicities were plotted on forest plots, respectively. RESULTS: Eight studies comprising 610 patients were included with two conference proceedings. SMD for VAS was -1.715 while proportionality for neurological improvement, local progression, and toxicities were 0.9 (90%), 0.03 (3%), and 0.121 (12.1%), respectively. CONCLUSIONS: Pain relief was evident by a decrease in VAS scores in the majority of patients. The majority showed neurological improvement and regained motor and sensory functions while an overwhelming population showed local tumor control with lesser patients developing tumor progression and radiation-induced toxicities. Short follow-ups and the absence of randomized trials advocates the need for further clinical researches to confirm the outcomes of IORT in spinal tumors.

Fertility preservation is an imperative goal in the clinical practice of radiation oncology: a narrative review.

With reduced cancer mortality in recent years, increased efforts must be put into safeguarding cancer survivors' long-term quality of life (QOL). Fertility preservation is recognised as a key component of QOL in survivorship. Concerns about fertility have been seen to significantly impact cancer patients' emotional and mental health as, generally, both malignancy and its treatment may cause a temporary or permanent reduction in infertility. This article reviews the primary effects of radiation therapy on male and female gonads and has further highlighted procedures through which the functioning of these organs can be protected before or during radiation treatment. We have also emphasised the importance of the establishment of multidisciplinary tumour boards and patient education regarding future reproductive function which is an important component of the care of individuals with cancer. This article highlights that infertility is a persistent and major concern that can add to long-term stress in cancer survivors, and education about fertility preservation before the initiation of any treatment is especially important.