Genetic markers of chronic lymphocytic leukemia: a retrospective study of 312 patients from a reference center in Lebanon.

Aim: Chronic lymphocytic leukemia (CLL) is a highly heterogenous hemopathy. Genetic stratification of CLL patients has important prognostic and therapeutic values - mainly immunoglobulin heavy chain variable region gene (IGHV) mutational status and the presence of cytogenetic abnormalities. The genetics of CLL in Lebanon is scarcely described in the literature. Patients & methods: In this work, we studied the genetic biomarkers of 312 Lebanese CLL patients. Results: Prominent IGHV genes were IGHV4-34, IGHV1-69 and IGHV3-30; and CLL #1 and #5 presented major subsets. Some similarities as well as major differences were highlighted when comparing our data with previously published data. Conclusion: The distribution of IGHV alleles in our series differed from previously described distributions, suggesting involvement of antigenic selection and regional variables in CLL pathogenesis.

Impact of ABO and Rhesus blood groups on COVID-19 susceptibility and severity: A case-control study.

Early evidence from China suggested that blood groups may be involved in susceptibility to COVID-19. Several subsequent studies reported controversial results. We conducted a retrospective matched case-control study that aims to investigate the association between blood groups and the risk and/or severity of COVID-19. We compared the blood groups distribution of 474 patients admitted to the hospital for COVID-19 between March 2020 and March 2021, to that of a positive control group of outpatients infected with COVID-19 and matched them for sex and age, as well as to the distribution in the general population. Three hundred and eighteen HC+ pairs with available blood group information were matched. The proportion of group A Rh+ in hospitalized patients (HC+) was 39.9% (CI 35.2%-44.7%), compared to 44.8% (CI 39.8%-49.9%) and 32.3% in the positive outpatient controls (C+) and the general population (C-), respectively. Both COVID-19-positive groups (HC+ and C+) had significantly higher proportions of group A Rh+ compared to the general population (p = 0.0019 and p < 0.001, respectively), indicating that group A Rh+ increases susceptibility to COVID-19. Although blood group A Rh+ was more frequent in the outpatients C+ compared to the hospitalized group HC+, the association did not reach statistical significance, indicating that blood group A Rh+ is not associated with severity. There was no significant relationship between COVID-19 and other blood groups. Our findings indicate that blood group A Rh+ increases the susceptibility for COVID-19 but is not associated with higher disease severity.

Prevalence of Her2-neu status and its clinicopathological association in newly diagnosed gastric cancer patients.

BACKGROUND: This study aimed to report the prevalence of HER2-neu in newly diagnosed early or metastatic gastric cancer (GC) patients, to determine the percentage of patients achieving various IHC scores correlating with the ISH results and to establish a database for GC patients in Lebanon. METHODS: This was a national, multicenter, descriptive and cross-sectional study in patients with histologically confirmed early or metastatic GC newly diagnosed. All eligible patients underwent the IHC and ISH tests in a central laboratory. Demographics, medical history and histopathology data were collected. RESULTS: One hundred fifty-seven patients were included (mean age at diagnosis: 63 ± 14.1 years) during a 3.5 year period. The prevalence of HER2-neu over expression was 21% (95% CI: 15.3-27.4) using ICH and ISH. Agreement between IHC and ISH results was significantly substantial (kappa = 0.681; p-value < 0.001). Over expressed HER2-neu status was significantly associated with high ECOG performance status only. CONCLUSIONS: The prevalence of HER2-neu over expression in newly diagnosed early or metastatic GC patients seemed to be high in Lebanon. The database generated allows to monitor trends in the epidemiology and management of GC.

Perceptions of the COVID-19 vaccine among patients with cancer: a single-institution survey.

Aims: This paper reports the results of a survey assessing the acceptance of the COVID-19 vaccine among patients with cancer. Patients and methods: In total, 111 adult patients with cancer from a single institution were asked to complete a questionnaire designed to assess their knowledge about the vaccine, their readiness to be vaccinated and the determinants of their decision. Results: 61.3% of the patients considered themselves more vulnerable to COVID-19 than the general population. Television, radio and newspapers were the major sources of information about the vaccine. A total of 55% of the patients were ready to be vaccinated and 14.4% refused the vaccine. The main reason for refusal was incompatibility with patients' disease or treatment. Conclusion: Most of the patients in this institutional sample accepted the COVID-19 vaccine. Better communication of information with patients is needed to decrease vaccine hesitancy.

Lay abstract Major cancer societies consider vaccinating patients with cancer against COVID-19 a priority. The investigators conducted a survey assessing perceptions of the vaccine among patients with cancer. A total of 111 patients were asked to complete a questionnaire evaluating their knowledge about the vaccine, their readiness to be vaccinated and the determinants of their decision. Most (61.3%) patients considered themselves more susceptible to COVID-19 than the general population. Television, radio and newspapers were the major sources of information about the vaccine. The majority of patients (55%) were ready to be vaccinated and 14.4% refused the vaccine. The main reason for refusal was incompatibility with patients' disease or treatment. Better communication with patients is needed to decrease vaccine hesitancy.

Non Hodgkin lymphoma in Lebanon: a retrospective epidemiological study between 1984 and 2019.

BACKGROUND: Lymphomas are ranked as the fifth most common cancer in Lebanon. There is concern about the need of information regarding the prevalence of lymphoid neoplasm particularly Non-Hodgkin lymphoma (NHL) subtypes in the Lebanese population. This study intended to establish a descriptive status of NHL histological subtypes distribution in Lebanon thus identifying the most common types, knowing that the literature is poor regarding the distribution of lymphoid malignancies particularly NHLs in Lebanon. METHODS: A bicenter retrospective descriptive study was performed. Patients aged above 18, diagnosed with NHL between January 1984 and March 2019 and registered in two Lebanese Medical centers were included in this study; 699 medical files were reviewed and the baseline characteristics of the disease were collected. Histological classification was based on the Working Formulation (WF) and World Health Organization (WHO) classification systems, whereas staging was based on the Ann Arbor system. Disease status was monitored with imaging studies. RESULTS: The mean age at diagnosis was 53.52 ± 17.46 years in the studied population, with 380 (54.4%) males and 319 (45.6%) females. B-cell lymphoma (BCL) accounted for 86.3% while T-cell neoplasms accounted for 13.7%. The most common subtype was diffuse large B-cell lymphoma (DLBCL) (54%) followed by follicular lymphoma (FL) (17.2%). Mantle cell lymphoma (MCL) represented 3% of all BCL and small lymphocytic lymphoma (SLL) comprised less than 2%. Mucosa-associated lymphoid tissue (MALT) and Burkitt's lymphomas represented 3 and 1.7% respectively. 36.5% of the patients had extranodal disease at diagnosis. High-grade tumor represented 80.1% with 33.1% stage IV disease. CONCLUSION: These observations indicate that the epidemiological patterns of NHLs in Lebanon were comparable to Western countries. Aggressive lymphomas account for the majority of NHLs in Lebanon.

Second-line Treatments of Advanced Hepatocellular Carcinoma: Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Advanced hepatocellular carcinoma (HCC) constitutes the second leading cause of cancer-related deaths. First-line therapy is either sorafenib or lenvatinib. Several treatment options have been recently added to the second-line treatment of advanced HCC. The aim of this network meta-analysis of randomized controlled trials was to compare the second-line treatments of advanced HCC. METHODS: Network meta-analyses were computed for overall survival (OS), progression-free survival, rates of grade 3 to 5 adverse events, and for treatment discontinuation due to adverse events. OS was considered to be the primary outcome of this study, and everolimus was chosen to be the common comparator for efficacy analyses and placebo for safety analyses. Subgroup analyses were computed for OS in patients with hepatitis B, patients with hepatitis C, Asian patients, patients with macrovascular invasion, and patients with extrahepatic metastases. RESULTS: Thirteen randomized controlled trials including 5076 patients and evaluating 11 agents were found to be eligible. Regorafenib [hazard ratio (HR)=0.60, 95% confidence interval (CI)=0.44-0.81] and cabozantinib (HR=0.72, 95% CI=0.55-0.95) were found to significantly prolong OS compared with everolimus. The effect of regorafenib on OS tended to be conserved across patient subgroups. Regorafenib was also found to significantly prolong progression-free survival (HR=0.46, 95% CI=0.35-0.62) and significantly increase the rates of grade 3 to 5 adverse events (odds ratios=3.18, 95% CI=2.22-4.54) and treatment discontinuation due to adverse events (odds ratios=2.67, 95% CI=1.21-5.87). CONCLUSIONS: This network meta-analysis concludes that, based on current evidence, regorafenib could be the agent of choice in the second-line treatment of HCC, with cabozantinib as a possible alternative for sorafenib-intolerant patients.

Treatment of cancer patients in their last month of life: aimless chemotherapy.

PURPOSE: The use of chemotherapy in the last month of life (CLML) of cancer patients is considered an aggressive approach to be avoided. We examined the practice of CLML in Lebanese cancer patients, and we investigated patient and tumor characteristics that justify this practice. To our knowledge, this is the first study describing CLML of Middle Eastern patients with advanced cancer. METHODS: We conducted this study at Hotel-Dieu de France University Hospital (HDF), Lebanon. Cases eligible for this study were all individuals diagnosed with cancer who died at HDF between the 1st of January and the 31st of December 2014. Demographic and clinical characteristics of the patients were obtained from the hospital registration records. Data concerning the management plan, primary malignancy and stage, chemo-sensitivity, line, type, and timing of chemotherapy in the last month of life were also obtained. RESULTS: Among the 130 cancer patients who were enrolled, CLML was administered to a total of 55 patients (42.3 %), of whom 26 patients (50 %) received more than one cytotoxic drug. Oral drug was only given to 9 patients (16.4 %). Interestingly, CLML increased the risk of death in the last month of life (p = 0.02), yet progression of disease constituted the major cause of death in this subgroup (54.6 %). The only variable to have statistical significant correlation with CLML was performance status (p = 0.03). The type of tumor and recent diagnosis of less than 2 months were also correlated to CLML (p = 0.03 and 0.024, respectively). CONCLUSION: The high percentage of patients receiving CLML underlines the difficulty of end-of-life discussions in patients from Middle Eastern societies. This is true in the context of a country with little availability of palliative care resources, where health policies should be more focused on incorporating palliative medicine in all medical strategies.

Personalized treatment is better than one treatment fits all in the management of patients with mCRC: a consensus statement.

The VEGF- (bevacizumab) and EGFR- (cetuximab and panitumumab) targeting monoclonal antibodies have become integral components of the first-line treatment strategies for patients with metastatic colorectal cancer (mCRC). Increasingly combination chemotherapy, with or without a targeted agent, is being used to facilitate curative liver resection and improve survival rates in patients with initially unresectable but potentially resectable mCRC. Currently, the only selective marker for the treatment of patients with mCRC is tumor RAS mutational status. BRAF status is a strong prognostic indicator. Medical and clinical oncologists from Central Asia, Russia, the Middle East, Africa and Turkey reviewed data for the use of targeted agents in the treatment of patients with mCRC and have formed recommendations for the biological of choice first-line for patients with mCRC.

The association between angiotensin receptor blockers and lung, bladder, and colon cancer development: A 10-year multicentric retrospective Lebanese study.

Cardiovascular diseases (CVD) are the leading cause of death globally, followed by cancer. Angiotensin II contributes greatly to CVD pathogenesis, and Angiotensin II receptor blockers (ARBs) constitute a mainstay in hypertension and CVD management. However, the relationship between ARBs and cancer initiation is controversial, with no clear data in Lebanon. Therefore, our study aimed to determine the association between ARBs intake and lung, bladder, and colorectal cancers development in the Lebanese population. A retrospective study was conducted on 709 subjects divided into 2 main groups: Control (subjects without cancer; n = 177), and Cases (patients with cancer (n = 532): lung, bladder, or colorectal), taking ARBs (n = 236, (n = 121 in control and n = 115 in cases)) or not (n = 473). Collected information included the patients demographics, comorbidities, cancer's risk factors, and ARBs dose and duration intake. Bivariate, multivariate, and binary logistic analyses were enrolled. ARBs use was significantly protective (P value = 0.000) against overall cancer development (odds ratio [OR] = 0.127) and against each, lung (OR < 1), bladder (OR < 1), and colorectal cancers (OR < 1). A duration-response relationship was established. This protective effect and the time-dependent relationship remained unchanged after omitting the most relevant risk factors. In summary, a significant overall protective effect of ARBs against lung, bladder and colorectal cancers was found. This beneficial response was time-dependent. These results can guide patients on treatment options and clinicians for informed decision-making.

Consensus on the management of platinum-sensitive high-grade serous epithelial ovarian cancer in Lebanon.

Ovarian cancer is the most lethal gynecologic cancer. The high grade serous epithelial (HGSE) subtype is the most aggressive and it often presents at advanced stages, while screening programs have not proven beneficial. Management of the advanced stages (FIGO III and IV), which constitute the majority of diagnoses, usually consists of platinum-based chemotherapy and cytoreductive surgery (primary or interval) followed by maintenance therapy. Currently, the standard-of-care for advanced newly diagnosed HGSE ovarian cancer, as per international medical societies, starts with upfront cytoreductive surgery, followed by platinum-based chemotherapy (mostly carboplatin and paclitaxel) and/or anti-angiogenic agent bevacizumab, then maintenance therapy with a poly(ADP-ribose) polymerase (PARP) inhibitor with/without/or bevacizumab (continued). PARP inhibitor use depends on the patient's genetic signature, mainly the breast cancer gene (BRCA) mutation and the homologous recombination deficiency (HRD) status. Therefore, genetic testing is recommended at diagnosis to inform treatment and prognosis. In line with the evolving standard-of-care for ovarian cancer, a panel of experts in treating advanced ovarian cancer convened to lay down practical recommendations on the management of advanced ovarian cancer in Lebanon; since the currently applicable guidelines by the Lebanese Ministry of Public Health for cancer treatment have not been updated yet to reflect the treatment paradigm shift brought upon by the development and approval of PARP inhibitors. The current work reviews the leading clinical trials on PARP inhibitors (as maintenance for newly diagnosed advanced and platinum-sensitive relapsed ovarian cancer), presents international recommendations, and proposes treatment algorithms for optimal local practice.

Statins, commonly coprescribed drugs, and concomitant risk factors: A protective, neutral, or harmful association with common cancer types development: A 10-year multicentric retrospective lebanese study.

Elevated blood levels of low-density lipoprotein cholesterol are a major cardiovascular risk factor, and cholesterol-lowering drugs are among the most prescribed drugs worldwide. Cancer is the second leading cause of death after cardiovascular diseases. The relationship between cancer development and statins intake is controversial, and there are no clear studies in Lebanon and the Middle East concerning this topic. Hence, our study aimed to search for any possible association of statin intake as well as other medications (proton pump inhibitors [PPI], metformin, Aspirin, Angiotensin-Converting Enzyme inhibitors, and fenofibrate) with lung, colorectal cancer (CRC), and bladder cancer development in the Lebanese population. A retrospective study was performed on 709 subjects divided into 2 main groups: control (no cancer ± statin intake), and cases (either lung, or colorectal, or bladder cancer ± statin intake). Collected data included the age and gender of the patient, socioeconomic status, presence of cardiovascular disease and comorbidities, cancer risk factors, and the intake type, dose, and duration of statins. Bivariate, multivariate, and binary logistic analyses were enrolled. Out of 709 participants, 63.2% were males and 75% were cancer-positive (24.1%: lung cancer, 26.7%: CRC, 24.1%: bladder cancer). The overall intake of statins was not shown to significantly affect cancer development. However, a duration-response relationship was established between Simvastatin and lung cancer (odds ratio [OR]=1.208) as well as bladder cancer (OR=1.189). No significant association was found between each statin and CRC. Although PPIs intake was associated with a possibly harmful effect on lung cancer development (OR=3.42), it revealed a protective association with CRC development (OR=0.38). Other risk factors such as smoking and age were strongly associated (harmful) with lung and bladder cancer development. Physical inactivity and a family history of CRC were each associated with a harmful effect on CRC development. A harmful association with the development of lung and bladder cancer was found with the increasing duration of intake of Simvastatin. Other drugs such as PPIs and specific risk factors were also associated negatively or positively with the development of these 3 cancers. These findings should be validated by further investigations to guide clinicians on optimal treatment options for their patients.

Diagnosis and management of patients with stage III non­small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review).

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.

Frequency and mutational spectrum of PIK3CA gene mutations in breast cancer patients: Largest and first report from Lebanon.

The PIK3CA pathway is one of the most frequently altered pathways in human cancers, especially in breast cancer with approximately 40% of HR+/HER2- advanced breast cancer cases exhibiting mutations in the PIK3CA gene. While the mutations can occur across the entire gene, the most common are observed in exon 9 corresponding to the helical domain, and in exon 20 encompassing the kinase domain. This study constitutes the first attempt at determining the frequency and mutational spectrum in Lebanese breast cancer patients. For this purpose, DNA samples from 280 breast cancer patients from across Lebanon were screened for PIK3CA mutations using the Therascreen® PIK3CA RGQ Real-time PCR assay. In line with previous reports, 38.57% of cases were positive for at least one PIK3CA mutation, among which approximately 59% were in exon 9 and 37% in exon 20. However, PIK3CA mutations are breast cancer are heterogeneous whereby 20% of known PIK3CA mutants might not be detected by compact PCR based assays. Thus, the adoption of comprehensive Next Generation Sequencing based panels to decipher the complete clinical, molecular and immunohistochemical profile of breast cancer tumor requires further investigation.

A Non-Interventional Multicenter Study of First-Line Bevacizumab in Combination with Chemotherapy in Patients with Metastatic Colorectal Cancer in Lebanon.

PURPOSE: When combined with chemotherapy, bevacizumab improves progression-free survival (PFS) in metastatic colorectal cancer (mCRC). This observational trial was designed to assess the safety and efficacy of bevacizumab plus first-line chemotherapy in a real-world setting in Lebanon. PATIENTS AND METHODS: A non-interventionaL multicenter study of first-LIne AVastin® (bevacizumab) in combination with chEmotherapy in patients with metastatic colorectal cancer (LLIVE) is a multicenter, prospective, Lebanon-based, observational study that enrolled mCRC patients who received first-line bevacizumab plus chemotherapy combination. The primary end point of the study was PFS. Secondary endpoints comprised the overall response rate (ORR) and the safety and tolerability of bevacizumab. RESULTS: A total of 196 patients were enrolled between July 2010 and August 2013. The median duration of follow-up was 11 months. Median duration of bevacizumab treatment was 4 months with FOLFOX being the chiefly chemotherapy regimen used in the first-line setting (26%). Median PFS was 8.22 months (95% confidence interval (CI): 7.005-9.443). The ORR was 50.3% (complete response 7.5%, partial response 42.8%). The most common adverse event encountered was hypertension (28%) followed by epistaxis (4.8%), diarrhea (4%), anemia (4%) and headache (4%). Grade 3/4 adverse events occurred in 15.2% of patients. CONCLUSION: The trial further substantiated the efficacy and safety of bevacizumab and chemotherapy in the first-line treatment of mCRC patients in Lebanon.

Triple-negative breast cancer in Lebanon: a case series.

OBJECTIVES: To determine the incidence, characteristics, and survival outcomes of triple-negative breast cancer patients in a medical oncology practice in Lebanon. METHODS: The pathology reports of all breast cancer cases diagnosed or treated in 1997-2008 were reviewed. RESULTS: One hundred seventy breast cancer cases (9.3%) of the 1,834 cases that were identified in this practice over a 10-year span had a triple-negative phenotype, with a median age at diagnosis of 52 years. The pathology distribution of those cases was as follows: invasive ductal carcinoma, 85%; medullary carcinoma, 5%; invasive lobular carcinoma, 5%; 95 cases (63%) were grade III. At diagnosis, 17% presented with stage I, 47% had stage II, 24% had stage III, and 12% had stage IV disease, whereas 11% had an inflammatory component. After a median follow-up of 17 months, 43 patients (25.3%) had relapsed and the most common sites of relapse were the brain (19%), lungs (19%), and bones (12%). The risk for recurrence peaked at 1.5 years and became almost nil after 3 years. Twenty patients received induction chemotherapy, among whom six (42.9%) had a complete response and six (42.9%) had a partial response to treatment. None of the patients progressed on neoadjuvant chemotherapy. The 5-year disease-free survival rate was 75% for stage I, 58% for stage II, and 40% for stage III patients, whereas the 5-year overall survival rate was 88% for stage I, 72% for stage II, and 63% for stage III patients. Adjuvant therapy was administered to 96% of patients, using a taxane-based regimen in 38% of cases. The median survival time for stage IV patients was 19 months, with a first line taxane-based regimen used in 50% of cases. CONCLUSIONS: The incidence of triple-negative breast cancer in Lebanon is similar to that described in the literature. In order to determine targets for future therapeutic options, it is essential to understand the biology of this particular breast cancer subtype.

Experience with palliative care in patients with advanced cancer at a tertiary care hospital in a developing country.

The importance of palliative care in patients with advanced cancer is established. Reports on the experience with palliative care in the Middle East region are limited. A prospective study was performed to characterize the palliative care experience at a tertiary care center in Lebanon and to identify the profile of patients requiring palliative care. This communication highlights the results of the study. Authors conclude that the profile of needs for individuals requiring palliative care in Lebanon is similar to westernized countries. Revisiting the continuum of cancer care is called for to better identify the optimal timing of intervention and avoid end of life distress.

[Chemoradiotherapy in early stage Hodgkin's lymphoma]. / Chimio-radiothérapie dans les lymphomes de Hodgkin-Stades précoces.

OBJECTIVE: To evaluate the response to and toxicities of chemo-radiotherapy (CT-RT) in patients with early stage Hodgkin lymphoma treated in our institution. MATERIALS AND METHODS: Retrospective study of 42 patients with early stage Hodgkin lymphoma treated between 2002 and 2007. RESULTS: The age of patients ranges from 11 to 57 with a mean of 30.7 years; the sex-ratio is 0.8 (19 males and 23 females). There are 33 cases of nodular-sclerosing Hodgkin lymphoma, 6 of mixed cellularity, one lymphocyte-rich, one interfollicular and one granulomatous. As for the stages, 31 Hodgkin lymphomas are stage IIA, 6 stage IA, 3 bulky and 2 stage IAe. The ABVD protocol was given to 38 patients, the VBVP to 3 patients and the ABV to one patient. IFRT was used with dose ranging from 19.8 to 39.6 Gy. The acute toxicity of chemotherapy was hematologic only, grade 1 anemia accounting for 11.1% and grade 2 anemia for 14.8%, grade 1 leukopenia for 51.8%, grade 2 leukopenia for 333% and grade 3 leukopenia for 14.8%. Dysphagia, radiodermitis and radiomucositis were seen after radiotherapy, accounting for 16.5%, 4.6% and 9.1% respectively. No long-term toxicity of the combined therapy was found. During the follow-up period, one relapse occurred and no death was reported. CONCLUSION: The overall survival (OS), the disease free survival (DFS) and the toxicities of the combined therapy CT-RT of the patients with early stage Hodgkin lymphoma stage IA and IIA treated in our institution were similar to those seen in the literature.

Hemophagocytic lymphohistiocytosis, a new cause of death during 'post-acute COVID-19 syndrome?' A case report.

'Post-acute coronavirus disease 2019 (COVID-19) syndrome' is a new term that was coined to describe a constellation of persistent symptoms and new complications following recovery from COVID-19 initial illness. Identifying post-COVID-19 complications is crucial for early diagnosis and subsequent initiation of therapies to ensure more favorable outcomes. Severe COVID-19-related hemophagocytic lymphohistiocytosis (HLH) has been previously described during the acute phase of the infection. It is characterized by hyperinflammation, multi-organ involvement, and hemophagocytosis. We report the case of a 69-year-old woman who presented, two weeks after recovery from COVID-19, with hyperosmolar state and high inflammatory markers. Bone marrow aspirate, flow cytometry, extensive viral panel and total body scan were performed. Review of bone marrow aspirate smear showed hemophagocytosis. Flow cytometry, viral panel, and total body scan were normal. The diagnosis of post COVID-19-related HLH was made. Unfortunately, the patient died despite adequate treatment. To our knowledge, this is the first case establishing a high probability of COVID-19-related HLH given its occurrence two weeks following a documented biological and clinical recovery. Awareness and early recognition of HLH features following COVID-19 recovery should prompt timely initiation of therapy.

Assessment of Lebanese healthcare professionals' awareness on acquired haemophilia: a cross-sectional study.

BACKGROUND: Acquired haemophilia A (AHA) is a rare immune-mediated disorder characterised by the development of autoantibodies against factor VIII. Morbidity and mortality are in general high due to multiple factors including the age of the patient, underlying diseases, toxic effects of available treatments and bleeding itself. OBJECTIVE: To assess the awareness about AHA among healthcare professionals (HCPs) in Lebanon where patients can present to non-haematologists with life-threatening bleeding disorders. METHODS: A cross-sectional survey was conducted in September and October 2017 all over Lebanon among HCPs. The survey covered: (i) the geographic area of practice and specialty; (ii) bleeding disorders encountered within the last 2 years; (iii) assessment of knowledge on AHA; and (iv) importance of increasing awareness on AHA among HCPs. RESULTS: A total of 362 participants completed and returned the questionnaire (response rate 100%). The majority of the HCPs were practicing in Beirut (n=164; 45.3%) and were internists (n=106; 29.3%). 332 (93%) HCPs have encountered patients with bleeding problems within the last 2 years all over Lebanon. 327 (92.1%) HCPs agreed that increasing awareness on AHA among health care professionals is important. HCPs gave an average of 75.9% of correct answers on the survey. CONCLUSIONS: Appropriate treatment and diagnosis are essential when dealing with AHA. Knowledge gaps exist in the clinical practice when dealing with patients who have AHA. This study shows the need for increasing awareness about AHA among HCPs in Lebanon regarding the diagnosis and treatment of this disorder.

Lebanese Real-World Experience in Treating Multiple Myeloma: A Multicenter Retrospective Study.

OBJECTIVE: The present retrospective multicenter study aims at documenting characteristics of multiple myeloma (MM) patients and the effect of autologous stem cell transplant (ASCT) on survival. METHODS: A total of 134 adult patients initiating any new MM therapy from January 2002 till December 2019 were included. Enrollment was stratified by disease subtype, induction protocol and transplant status. The characteristics and survival outcomes were recorded. RESULTS: Mean age at diagnosis was 61.91 ± 10.83 years, with 62.7% male patients. Regarding the prognostic MM International Staging System (ISS), stage 3 was the most common at diagnosis with 50.8% of patients followed by stage 1 (25.4%) and stage 2 (23.8%). Maintenance treatment was given in 88.5% of the patients. 24.6% patients were transplanted, 41% were not and the remaining were unknown or still in induction. 86.1% of patients were alive at data cut off. A significantly higher mean progression free survival (PFS) was found in transplant patients (p=0.016). Using cox regression, creatinine >2 mg/dl (HR3.78) and hypercalcemia >11 mg/dl (HR=6.48) were significantly associated with a shorter PFS1. A significantly shorter overall survival (OS) was associated with hypercalcemia (HR=6.58), as well as male gender though not statistically significant in the latter. Difference in survival distributions by treatment was not statistically significant (bortezomib thalidomide dexamethasone (VTD) (p=0.211), bortezomib cyclophosphamide dexamethasone (VCD) (p=0.111) or bortezomib Revlimid dexamethasone (VRD) (p=0.312)). The interaction between ISS stage on diagnosis and transplant was not significantly associated with the overall survival. CONCLUSION: The results of our retrospective study are in conformity with international data emphasizing the role of transplant in the treatment algorithm of newly diagnosed transplant-eligible multiple myeloma patients.