Consensus guidelines for the management of intracranial metastases for low- and middle-income countries.

Metastatic tumours are among the most common types of brain tumours. However, in low- and middle-income countries (LMICs), the numbers are considerably lower. This does not necessarily indicate a decreased incidence but rather points to decreased survival rates or limited access to healthcare. The challenge of achieving better outcomes, along with associated costs and resource constraints, often hinders the effective management of brain metastasis. Even in cases where localised disease can potentially be managed to improve survival, these challenges persist. The purpose of these guidelines is to address these challenges and outline a management strategy within the context of LMICs.

Consensus guidelines for the management of adult low-grade gliomas for low and middle-income countries.

Low-grade gliomas (LGG) are brain tumors of glial cells origin. They are grade 1 and grade 2 tumors according to the WHO classification. Diagnosis of LGG is made through imaging, histopathological analysis, and use of molecular markers. Imaging alone does not establish the grade of the tumor and thus a histopathological examination of tissue is crucial in establishing the definite histopathological diagnosis. Clinical presentation varies according to the location and size of the tumor. Surgical resection is strongly recommended in LGG over observation to improve overall survival as surgery leads to greater benefit due to progression-free survival. Radiation has shown benefits in LGG patients in randomized controlled trials and chemotherapy with temozolomide has also shown good results. This paper covers the principles of low-grade gliomas management and summarizes the recommendations for the LMICs.

Consensus guidelines for the management of adult high-grade gliomas for low and middle-income countries.

High-grade glioma (HGG), a formidable and often incurable disease, presents an even greater challenge in low- and middle-income countries (LMICs) where resources and medical expertise are scarce. This scarcity not only exacerbates the suffering of patients but also contributes to poorer clinical outcomes. Particularly in LMICs, the underrepresentation of the population in clinical trials and the additional hurdles posed by financial constraints underscore an urgent need for contextspecific management strategies. In response, we have rigorously evaluated recent guidelines from leading medical societies, adapting them to suit the specific needs and limitations of the local context in Pakistan. This effort, undertaken in collaboration with local physicians, aims to provide a comprehensive, standardised approach to diagnose, treat, and follow-up with HGG patients. By focussing on the best available clinical evidence and judicious use of limited resources, we strive to improve patient care and outcomes in these challenging settings.

A case report and literature review on primary intracranial malignant melanoma: Challenges and insights.

INTRODUCTION AND IMPORTANCE: Primary central nervous system (CNS) melanoma is a rare entity. Primary CNS malignant melanomas account for 1 % of melanomas and 0.07 % of intracranial tumours. These are highly aggressive and are associated with poor prognosis. Herein, we have discussed one such rare case of PIMM. CASE PRESENTATION: 62-year-old man with primary CNS melanoma underwent craniotomy and resection of left temporal lesion. Postoperative MRI showed no evidence of residual disease. He received 28 fractions of radiation. Follow-up MRI showed no evidence of disease. However, he later developed worsening symptoms and repeat imaging revealed disease progression with hydrocephalus and drop metastasis to spine. He underwent VP shunting and was started on Temozolomide. He progressively declined functionally and eventually died from his disease. CLINICAL DISCUSSION: Primary CNS melanoma is characterized by its rarity, challenging diagnosis, and aggressive behaviour. Current literature suggests limited treatment options, which depend on complete resection of the primary tumour. Molecular analysis may play a key role in deciding future treatment options, including immune checkpoint inhibitors and targeted therapies targeting the BRAFV600E mutation. CONCLUSION: Primary intracranial malignant melanoma (PIMM) is an extremely rare tumour of CNS, and its treatment paradigm is very limited based on available literature. Currently any long-term survival depends on the complete resection of tumour. Our case is unique as it talks about the limited therapeutic options in case of rapidly declining performance status in a resource constraint setting.

A Curious Case of Primary Gastric Mucosal Melanoma.

Malignant melanoma is a neoplasm of melanin-producing cells predominantly of cutaneous origin, which uncommonly develops within gut mucosa. We present the case of a 58-year-old woman with complaints of abdominal pain, loss of appetite and weight. Esophagogastroduodenoscopy revealed a gastric mass and systemic imaging demonstrated widespread nodal and bilateral adrenal gland involvement. Histopathology of the gastric mass confirmed primary malignant mucosal melanoma of the stomach. The patient received three cycles of Nivolumab but did not respond, and thus, was then offered best supportive care. Although infrequent, mucosal melanoma can arise from the gastrointestinal tract, and in contrast to the cutaneous form, advanced disease usually has a dismal prognosis and responds poorly to immune checkpoint inhibitors. Primary gastric melanoma is an aggressive disease that is diagnosed by exclusion after the differential diagnosis of metastasis from a cutaneous or unknown primary site has been conducted. If available, patients with treatment-naïve mucosal melanoma should be considered for enrollment in clinical trials.

Trick or Treat: An Intrahepatic Intraductal Papillary Neoplasm of the Bile Duct.

An intraductal papillary neoplasm involving the biliary tree is an unusual premalignant condition of epithelial origin, identified by its cystic dilatation of the biliary channels. Being a slow-growing tumor, surgery offers the best curative rate, especially in the setting of a low-grade disease. Here, we present a case of a localized, low-grade, intraductal papillary neoplasm of the bile duct (IPNB), residing in the liver, which was treated with resection of the liver lobe. The adjuvant treatment and prognosis highly depend upon the presence of dysplasia or a co-existent invasive malignancy. To the best of our knowledge, being a rare entity, this is the first case to be reported from Pakistan.

"Outcomes of COVID-19 infection in patients with hematological malignancies- A multicenter analysis from Pakistan".

PURPOSE: COVID-19 infection resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began to spread across the globe in early 2020. Patients with hematologic malignancies are supposed to have an increased risk of mortality from coronavirus disease of 2019 (COVID-19) infection. From Pakistan, we report the analysis of the outcome and interaction between patient demographics and tumor subtype and COVID-19 infection and hematological malignancy. PATIENTS AND METHODS: This multicenter, retrospective study included adult patients with a history of histologically proven hematological malignancies who were tested positive for COVID-19 via PCR presented at the oncology department of 5 tertiary care hospitals in Pakistan from February to August 2020. A patient with any known hematological malignancy who was positive for COVID-19 on RT-PCR, was included in the study. Chi-square test and Cox-regression hazard regression model was applied considering p ≤ 0.05 significant. RESULTS: A total of 107 patients with hematological malignancies were diagnosed with COVID-19, out of which 82 (76.64%) were alive, and 25 (23.36%) were dead. The significant hematological malignancy was B-cell Lymphoma in dead 4 (16.00%) and alive group 21 (25.61%), respectively. The majority of the patients in both the dead and alive group were on active treatment for hematological malignancy while they came positive for COVID-19 [21 (84.00%) & 48 (58.54%) p 0.020]. All patients in the dead group were admitted to the hospital 25 (100.00%), and among these, 14 (56.00%) were admitted in ICU with a median 11 (6-16.5) number of days. Among those who had contact exposure, the hazard of survival or death in patients with hematological malignancies and COVID-19 positive was 2.18 (CI: 1.90-4.44) times and 3.10 (CI: 2.73-4.60) times in patients with travel history compared to no exposure history (p 0.001). CONCLUSION: Taken together, this data supports the emerging consensus that patients with hematologic malignancies experience significant morbidity and mortality resulting from COVID-19 infection.