Chemoradiotherapy or chemotherapy as adjuvant treatment for resected gastric cancer: should we use selection criteria?

BACKGROUND: The management of gastric adenocarcinoma is essentially based on surgery followed by adjuvant treatment. Adjuvant chemotherapy (CT) as well as chemoradiotherapy (CTRT) have proven their effectiveness in survival outcomes compared to surgery alone. However, there is little data comparing the two adjuvant approaches. This study aimed to compare the prognosis and survival outcomes of patients with gastric adenocarcinoma operated and treated by adjuvant radio-chemotherapy or chemotherapy. MATERIALS AND METHODS: We retrospectively evaluated 80 patients with locally advanced gastric cancer (LGC) who received adjuvant treatment. We compared survival outcomes and patterns of recurrence of 53 patients treated by CTRT and those of 27 patients treated by CT. RESULTS: After a median follow-up of 38.48 months, CTRT resulted in a significant improvement of the 5-year PFS (60.9% vs. 36%, p = 0.03) and the 5-year OS (55.9% vs. 33%, p = 0.015) compared to adjuvant CT. The 5-year OS was significantly increased by adjuvant CTRT (p = 0.046) in patients with lymph node metastasis, and particularly those with advanced pN stage (p = 0.0078) and high lymph node ratio (LNR) exceeding 25% (p = 0.012). Also, there was a significant improvement of the PFS of patients classified pN2-N3 (p = 0.022) with a high LNR (p = 0.018). CTRT was also associated with improved OS and PFS in patients with lymphovascular and perineural invasion (LVI and PNI) compared to chemotherapy. CONCLUSION: There is a particular survival benefit of adding radiotherapy to chemotherapy in patients with selected criteria such as lymph node involvement, high LNR LVI, and PNI.

The perception of burnout and related influencing factors in Tunisian oncology nurses.

BACKGROUND: Oncology nurses constantly provide emotional support to patients and are confronted with their suffering, which represents chronic stress leading to the development of burnout syndrome. AIM: This study aimed to evaluate the prevalence of burnout and identify associated factors in a sample of oncology nurses. METHODS: We conducted a descriptive cross-sectional study with 70 oncology nurses at the Salah Azaiez Institute of Oncology in Tunisia. Burnout was assessed using the Maslach Burnout Inventory Human Service Survey. This study follows the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Guidelines. RESULTS: Burnout affected 60 nurses (85.7%), with a high level in 20% of cases. High scores of emotional exhaustion, depersonalisation, and low personal accomplishment were recorded in 65.7%, 50% and 25.7% respectively. Emotional exhaustion was associated with higher age, marital status, having 2 or 3 or more dependent children, number of patients under care exceeding 15, professional experience and history of psychiatric problems. Depersonalisation was correlated with age, marital status, professional grade and history of psychiatric problems. Low levels of personal accomplishment increased with the number of patients under care, history of psychiatric problems and the regret of professional choice. CONCLUSION: Burn-out is a reality in oncology hospital with an alarming rate. Interventions including rationalisation of workload, support groups, training in emotion and stress management would improve the mental health of these nurses and increase their performance. The screening for burnout should be included as a regular practice in health promotion programmes for oncology health professionals, particularly for a vulnerable subgroup that possesses the risk mentioned above factors.

Lymph node ratio as an indicator of nodal status in the assessment of survival and recurrence in vulvar cancer: A cohort study.

BACKGROUND: Inguinal lymph node (LN) metastasis and particularly the number of metastatic lymph nodes (NMLN) represent a determinant prognostic factor in vulvar squamous cell carcinoma (VSCC). However, the NMLN may be related to the number of removed LNs. Therefore, the lymph node ratio (LNR) reflects not only the burden of LN involvement but also the quality and extent of lymphadenectomy. OBJECTIVES: To investigate the value of the LNR and the count of LN on overall survival (OS) and recurrence-free survival (RFS). DESIGN: This study is a retrospective, longitudinal, institution-based study. METHODS: This study included 192 patients treated for VSCC at the Salah Azaiez Institute between 1994 and 2022. Clinical, pathological, and evolutionary data were reported. Survival curves were generated by the Kaplan-Meier method, and predictive factors of outcome were analyzed using Cox proportional hazards models. RESULTS: Surgery consisted of a radical vulvectomy, hemivulvectomy, and pelvic exenteration in, respectively, 96.4%, 2.1%, and 1.6% of cases followed by adjuvant radiotherapy in 38.5% of cases. LN dissection was bilateral in 88.5% of cases. LNR = 0, LNR = 0-0.2, and LNR ⩾0.2 were recorded in, respectively, 64.7%, 22.1%, and 13.2% of cases. With a mean follow-up time of 35 ± 42.06 months, the 5-year OS was 52.5% and the 5-year RFS was 55.8%. On multivariate analysis, the independent prognostic factors of OS were the LNR (hazard ratio (HR) = 5.702; 95% confidence interval (CI) = 2.282-14.245; p < 0.0001), Federation of Gynecology and Obstetrics (FIGO) stage (HR = 2.089; 95% CI = 1.028-4.277; p = 0.042), and free margins (HR = 2.247; 95% CI = 1.215-4.155; p = 0.01). Recurrences were recorded in 37.5% of cases. Independent prognostic factors of RFS were the LNR (HR = 2.911; 95% CI = 1.468-5.779; p = 0.002), FIGO stage (HR = 1.835; 95% CI = 1.071-3.141; p = 0.027), and free margins (HR = 2.091; 95% CI = 1.286-3.999; p = 0.003). CONCLUSION: Surgical margin, FIGO stage, and LNR represent the independent prognostic factors of survival and LNR showed superior prognostic predictive accuracy compared with the revised 2021 FIGO staging system for predicting OS and RFS in VSCC.

A Late Recurrent Metastatic Breast Cancer Mimicking Primary Pancreatic Cancer: Case Report.

Metastasis to the pancreas from malignant tumors is a rare event, representing only 1% to 2% of all pancreatic neoplasms. They occur in 2 different clinicopathological settings: as a manifestation in widespread metastatic disease or as an isolated mass in the pancreas. We report the case of a 41-year-old woman who had a history of invasive lobular breast cancer treated with radical surgery, chemotherapy, and radiotherapy. After 21 years of total remission, she presented for severe lower back pain with jaundice, nausea, and loss of 9 kg in 3 months. Abdominal computed tomography demonstrated a hyper vascularized, irregular solid lesion of 2.6 cm × 2.1 cm in the head of the pancreas with discreet biliary duct dilatation and coelio-mesenteric enlarged lymph nodes measuring 2 cm. The diagnosis of pancreatic metastasis from a lobular breast carcinoma was made by percutaneous biopsy of pancreatic lesion. The multidisciplinary committee decided a palliative treatment. The patient received chemotherapy. The take home message from his case is that we should keep in mind the hypothesis of a solitary metastasis to the pancreas, when the pancreatic lesion develops in a patient who had a clinical history of previous neoplasm especially in those which is known to potentially metastasize to pancreas.

An isolated vaginal metastasis from rectal cancer: a case report.

INTRODUCTION: Vaginal metastasis from colorectal cancer is a rare occurrence, typically associated with other metastatic lesions. Isolated metastasis is exceedingly uncommon, with only a few cases documented in the literature. Vaginal involvement in colorectal cancer primarily results from direct contiguous spread from the primary tumor. CASE PRESENTATION: We present the case of a 70-year-old African woman diagnosed with adenocarcinoma of the middle rectum. She underwent chemotherapy, radiotherapy, and subsequent anterior resection. After 2 months, an isolated metastasis of rectal cancer was identified in the lower third of the left vaginal wall, confirmed by biopsy. Colonoscopy ruled out colorectal recurrence. Thoraco-abdominal computed tomography scan showed no distant metastases. The patient underwent abdominoperineal resection, removing the lateral and posterior vaginal wall with free macroscopic margins and a definitive colostomy. The final histopathological analysis confirmed the diagnosis of moderately differentiated adenocarcinoma of the vagina, measuring 5 × 4.5 cm. The rectal wall was extrinsically invaded by the tumor down to the muscularis propria while respecting the rectal mucosa. Resection margins were negative. The patient was discharged 1 week postoperation with no complications. Adjuvant chemotherapy was indicated, and the patient is currently tolerating the treatment well. CONCLUSION: Vaginal metastases from colorectal cancer are extremely rare. A vigilant gynecological examination is recommended during the follow-up of colorectal cancer patients. Diagnosis can be challenging, especially if the metastatic lesion is small and asymptomatic, even after standard radiological examination. Surgical resection followed by chemotherapy is a valid option for patients with early isolated metastases.

Exceptional lymph node recurrence of an unusual ovarian tumor 16 years later: a case report.

BACKGROUND: Sex cord-stromal tumors with annular tubules are a rare tumor accounting for less than 1% of all ovarian malignancies. However, they are characterized by very late recurrence, which can be as late as 30 years after diagnosis and treatment. CASE PRESENTATION: A 16-year-old female Caucasian patient was treated in our department for a stage IA ovarian sex cord-stromal tumors with annular tubules. She underwent a left salpingo-oophorectomy and ipsilateral pelvic node biopsy with no adjuvant treatment. She was seen for amenorrhea after being lost to follow up for 16 years. The diagnosis of recurrence was made by radiology and the elevation of serum inhibin B level. The patient underwent resection of the tumor, left segmental colectomy, and paraaortic lymphadenectomy because the mass was massively adherent to the left mesocolon. Histology confirmed the diagnosis with no metastatic lymph nodes. No adjuvant therapy was indicated. The patient was lost to follow-up again for 4 years and re-presented for amenorrhea. Serum inhibin B level was high. A second recurrence was suggested, and the patient underwent a laparoscopic surgery. We performed left pelvic and paraaortic lymphadenectomy, and 3 months after surgery the patient was pregnant. CONCLUSION: Sex cord-stromal tumors with annular tubules is a slow-growing ovarian tumor with a high potential for recurrence and metastasis. Surgery is the mainstay of treatment. Due to the rarity of these tumors, they are often unsuspected and thus incompletely staged before primary surgery; the diagnosis is made by histological examination. The prognosis of these patients is unknown, and they require long-term follow-up.

Primary thyroid lymphoma: a case series.

INTRODUCTION: Primary Thyroid Lymphoma (PTL) is defined as lymphoma involving the thyroid gland alone or the thyroid gland and adjacent neck lymph nodes without contiguous spread or distant metastases at the time of diagnosis. Most thyroid lymphomas are B cell lymphomas, and 98% of all PTL cases are non-Hodgkin's lymphoma. It is a rare disease accounting for around 5% of the thyroid neoplasms and 2% of extranodal lymphomas. If properly diagnosed and treated, the prognosis is favorable. CASE PRESENTATION: Five cases (three men and two women) of PTL were diagnosed and treated in our institute between January 2005 and September 2019. These are 5 cases of Caucasian origin. The mean age was 76.2 (range: 63-95 years); one patient had associated hypothyroid. One patient had a medical history of breast cancer; one was hypothyroid, and four were euthyroid at the diagnosis. In 4 of these patients, PTL started with compressive symptoms. No patients underwent fine needle aspiration cytology (FNAC) or biopsy for the diagnostic only. In sonography, two cases showed bilateral nodules with goiter; in the three cases it showed nodules in the lobe and isthmus. Technetium-99m scintigraphy was performed on only two patients. Bone Marrow Biopsy (BMB) showed normal cellularity in 4 cases and only one case showed tumor cells. LDH levels were increased in all cases. The extension was evaluated in all patients with cervical and thoracic CT scans, Bone Marrow Biopsy (BMB), beta-2 microglobulin, and serum lactate dehydrogenase (LDH) levels. Three cases were staged as IE and two cases as IIE. Three patients underwent total thyroidectomy; two of them underwent cervical lymph node dissection. Two patients underwent lobectomy. All were diagnosed with lymphoma postoperatively and all were diffuse large B cell lymphoma (DLBCL). One patient completed treatment with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone), and two cases received adjuvant chemo-radiotherapy (30 Gy). Two patients died immediately after surgery. CONCLUSION: PTL is a rare disease whose diagnosis should be considered in cases of rapidly growing goitres. Timely needle biopsy in suspected cases can avoid unnecessary surgery. Systemic treatment is required, depending on the stage of the tumour.

Cutaneous metastasis as a first presentation of lung carcinoma: a case series.

INTRODUCTION: Cutaneous metastases (CM) revealing lung carcinoma are extremely rare, accounting for 0.8%. The diagnosis is guided by histology and immunohistochemistry. Treatment is palliative. The prognosis is poor. CASE PRESENTATION: This is a retrospective study of the available clinical and histological records of four North African patients with CM revealing lung cancer treated at our institute between 2004 and 2010. Three men and one woman were registered. The mean age was 54.5 years (38-74 years). Two patients had primary adenocarcinoma, one patient had small cell carcinoma and one had squamous cell carcinoma. Treatment was based on chemotherapy in two cases and antalgic radiotherapy in two cases, one patient underwent surgical resection as the lesion was infected. The overall survival after diagnosis was between one and four months. CONCLUSIONS: A skin nodule can be the first symptom revealing lung cancer. A rare clinical presentation that should not be taken for a benign nodule, the biopsy and histological study with immunohistochemistry confirm the diagnosis.

A huge prolapsed cervical leiomyoma: A case report.

INTRODUCTION AND IMPORTANCE: Uterine leiomyoma is the most common pelvic tumor in women. Its cervical location is rare and may extend into the vagina in 2.5 % of cases. Treatment of cervical fibroids includes either myomectomy or hysterectomy, depending on the patient's profile and the tumor's characteristics. These fibroids challenge the surgeon because of their proximity to vital pelvic structures and their likelihood of causing surgical complications. CASE PRESENTATION: A 47-year-old woman presented with abdominopelvic pain and a bulky necrotic mass protruding out of her vagina. CT scan showed a large heterogeneous anterior mass of the cervix measuring 30 cm prolapsed in the vagina. She underwent a total hysterectomy with complete resection of the cervical mass. The histopathological report confirmed the diagnosis of a cervical leiomyoma with no signs of malignancy. CLINICAL DISCUSSION: Three types of cervical leiomyoma are known: interstitial, supra-vaginal, and polypoidal. The last one, observed in our case, is the rarest type. When prolapsed in the vagina, cervical leiomyoma can outgrow its blood supply and become necrotic. Several approaches are available for the management of cervical leiomyomas. The approach choice depends on many factors such as the tumor size and location, its extent, and the desire for fertility. CONCLUSION: This report describes the case of a large gangrenous and prolapsed non-pedunculated cervical leiomyoma which remains a rare and disabling complication of this benign tumor for which hysterectomy remains the treatment of choice.

[Male breast cancer: about 123 cases collected at the Institute Salah-Azaiz of Tunis from 1979 to 1999]. / Le cancer du sein chez l'homme: à propos de 123 cas colligés à l'institut Salah-Azaïz de Tunis de 1979 à 1999.

Male breast cancer is rare compared to its female counterpart representing less than 1% of cancer in men. The objective of our retrospective study is to report the epidemiologic and clinical profile and to analyse the therapeutic results and prognostic factors in a Tunisian population collected during a period of 20 years at a single institution. We collected from 1979 to 1999, all the histological confirmed male breast cancers treated at our institution. We analyse the following data: age, clinical presentation and features, therapeutic protocol, results and prognostic factors. Survival was done with the Kaplan-Meier method and comparison with the log-rank test. 123 cases of male breast carcinoma were collected with a median age of 65 years. Most patients (62.2%) have an advanced T4 disease with bilateral lesions in 4 cases. Infiltrating ductal carcinoma represent 91% of all tumours. 85% of tumours expressed hormonal receptor. The treatment consisted in a radical mastectomy in 93 cases (84%) followed by radiotherapy, chemotherapy and in many cases by hormonotherapy. After a median follow up of 26 month, 22 patients presented loco regional recurrence and 41 metastases. Estimated 5-year survival rate was 62%. The presence of metastasis, nodal involvement, advanced disease, and grade affected survival. Male breast cancer represent at our institution 1 % of the male cancers treated comparable to the literature data. T4 tumours represent a higher rate, the treatment approach is the standard applicable in breast cancer; prognostic factors are the classical one like breast cancer in women.