Esophageal cancer in Iran; a population-based study regarding adequacy of cancer surgery and overall survival.

AIMS: Prognosis of esophageal cancer (EC) is poor. Population-based studies regarding EC survival and adequacy of cancer surgery (ACS) from developing countries are lacking. We aimed to evaluate EC patients' survival and ACS in a population-based setting for the first time from Iran. METHODS: We randomly selected 409 cases from all 3048 newly diagnosed EC patients who were registered in the nationwide cancer registry in calendar year 2005-2006 and followed them until 2009. An expert panel in Cancer Institute of Iran reviewed adequacy of esophageal cancer surgery on a national basis. RESULTS: Overall three-year survival rate was 17%. The median (95% CI) survival time of all patients and cases who underwent surgery alone were 8.5 (6.9-10.1) and 6.0 (3.1-8.9) months, respectively. The hospital mortality was 27.8% among the operated patients. Only 6.8% of cases had documented free circumferential resection margin and merely 4.0% of patients experienced resection of more than 15 lymph nodes during surgery. CONCLUSIONS: In Iran, the overall survival of EC patients with different treatment modalities are slightly less than those reported from high-income countries, but cases with surgery alone as the main treatment had worse outcome compared with their counterparts in developed countries. Surgery with curative intent has not been performed in most cases in Iran. It seems current clinical outcome of EC patients could be improved with surgical quality improvement and/or more use of chemoradiation in Iran.

Utility of endoscopic ultrasonography in the evaluation of dilated common bile duct of undetermined etiology.

INTRODUCTION: Occasionally, common bile duct (CBD) dilatation is discovered while working up patients for various causes. Not infrequently, the usual imaging modalities fail to identify the cause and endoscopic ultrasonography (EUS) becomes necessary. The aim of this study is to assess the value of EUS in identifying the cause of CBD dilatation undiagnosed by transabdominal ultrasonography. PATIENTS AND METHODS: During 1 year, 152 consecutive patients who were referred for evaluation of dilated CBD (diameter ≥7 mm) discovered incidentally during transabdominal ultrasonography were included. Final diagnoses were confirmed by endoscopic retrograde cholangiopancreatography, EUS-guided fine-needle aspiration, surgical exploration, or clinical follow-up of at least 10 months. RESULTS: One hundred and fifty two patients (54% female) with dilated CBD were included. Mean age of patients was 60 ± 17 years. The final diagnoses was choledocholithiasis in 32 (21.1%), passed CBD stone in 35 (23%), opium-induced CBD dilation in 14 (9.2%), post-cholecystectomy states in 20 (13.1%), ampullary neoplasia in 15 (15.8%), cholangiocarcinoma in 14 (9.2%) and pancreatic head cancer in 9 (5.9%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS for patients with abnormal EUS was 89.5%, 100.0%, 100.0%, 91.2%, and 90.9%, respectively. CONCLUSION: After diagnosis of CBD dilation by transabdominal ultrasonography, EUS may be a reasonable next choice for determining the etiology of dilated CBD.

Twenty years of breast cancer in Iran: downstaging without a formal screening program.

BACKGROUND: breast cancer (BC) is the most common malignancy among Iranian women. Although the relative incidence of BC is low, the cause-specific mortality is much higher than developed countries. The present study surveyed the overall trend of BC in Tehran. PATIENTS AND METHODS: all breast pathologic records were studied in five major hospitals in Tehran during three phases (1: 1985-1995; 2: 1996-2000; and 3: 2001-2005). Malignant cases were classified according to the tumor-node-metastasis classification. Data were compared across the study. RESULTS: Of 9050 medical records from male and female patients with 'breast disease', 2946 females with BC were included. A significant increase in the diagnosis of palpable early BCs (stage II increased, stage III decreased) was observed between phases 1 and 2. A relative increases in stages 0 and I were noted between phases 3 and 2. Nevertheless, 76.8% of cases were T2 or higher and 65.3% had positive lymph nodes in the last phase. The proportion of patients with stage IIIb was increased in phase 3, despite the reduction in phase 2. CONCLUSIONS: despite the relative improvement in the status of BC patients, the vast majority are diagnosed in advanced stages. Specific screening measures should be implemented in Iran.

Methotrexate hepatotoxicity in patients with rheumatoid arthritis.

BACKGROUND Increases in aminotransferases (transaminitis) are potential major adverse reactions seen with long-term use of methotrexate (MTX). The aim of this study, therefore was to evaluate the incidence of MTX induced hepatotoxicity and its risk factors among rheumatoid arthritis (RA) patients. METHODS This retrospective study described 286 patients with RA who received ≥ 7.5 mg MTX weekly in an academic rheumatology clinic over a 15 year period. The results of serial liver function tests, concurrent MTX dose, cumulative dose and use of hepatotoxic drugs were collected and statistically analyzed according to a consecutive elevation in aminotransferases which occurred over at least a two week interval. RESULTS During the study period, 286 patients (84.4% female) with mean age of 46.6±12.7 years (18-84 years) were enrolled. Transaminitis occurred among 23.7% of patients (incidence: 6.9 per 100 person-years) during 40.5±34.6 month's exposure to MTX (989.6 person-years). The time difference between onset of therapy and occurrence of transaminitis was 22.1±22.0 months. The only significant factor related to the occurrence of transaminitis was the duration of MTX therapy. The average duration of treatment among patients with transaminitis (59.6±42.3 months) was greater than those with no transaminitis (p<0.001). The cumulative dose of MTX was significantly related to the occurrence of transaminitis (p<0.001). CONCLUSION MTX hepatotoxicity is a common complication of long-term treatment with MTX. It is associated with mild liver enzyme elevation and related to the duration of therapy.

Endoscopic lesions in low-to average-risk patients with minimal bright red bleeding from midline anal fissures. How much should we go in?

BACKGROUND: Anal fissure is a common condition in young patients, and the main symptoms include anal pain and bleeding. Our aim was to determine the need to perform lower gastrointestinal endoscopy on patients with midline anal fissure who present with minimal bright red rectal bleeding and who are at low risk for colorectal neoplasia. METHODS: Patients with midline anal fissure who reported small amounts of red blood on toilet paper, toilet bowl or stool after defecation were evaluated. Patients with alarm signs (recently altered bowel habit, weight loss, anemia and family or personal history of colorectal neoplasms) were excluded. A total of 134 patients (80 female and 54 male, aged 35.8+/-11.4 years) were studied. Patients younger than 40 years underwent flexible sigmoidoscopy and colonoscopy was used for older ones. RESULTS: Fissures were posterior in 106 cases (79.1%) and anterior in 27 cases (20.1%); one patient (0.7%) had both anterior and posterior fissures. The lower gastrointestinal endoscopy was normal in 120 patients (89.6%), and 36 patients (26.9%) had associated internal hemorrhoids. Adenomatous polyps were found in 4 cases (3.0%), ulcerative colitis in 8 (6.0%) and Crohn's disease in one patient (0.7%). There was no case of adenocarcinoma. CONCLUSIONS: Clinical evaluation plus rectoscopy might be the appropriate evaluation in this selected group of patients, if our results are confirmed by further studies.