Treatment efficacy and tolerability of intravesical bacillus Calmette-Guerin (BCG)-RIVM strain: induction and maintenance protocol in high grade and recurrent low grade non-muscle invasive bladder cancer (NMIBC).

BACKGROUND: BCG-RIVM strain was used in many treatment protocols for non-muscle invasive bladder cancer only as induction courses. Cho et al. (Anticancer Res 2012) compared BCG-RIVM induction and 'standard' maintenance (Lamm et al., J Urol. 2000) to mitomycin C. They found no statistically significant differences regarding disease recurrence and progression. The purpose of our study was to determine the efficacy & tolerability of this specific BCG RIVM strain, using six-weekly, induction course and single monthly instillations as maintenance for one year, in high risk recurrent, multifocal low grade and multifocal high grade pTa/pT1, CIS transitional cell carcinoma of bladder. METHODS: From 2003-2012, BCG-naive patients treated with intravesical BCG-RIVM for high-risk multifocal NMIBC were identified. Transurethral resection of bladder tumor (TURBT) and re-staging TURBT within six weeks, was done for accurate staging and complete elimination of disease. A six-weekly induction course, started 2-3 weeks after the last TURBT, followed by monthly maintenance protocol for one year. Recurrence, progression, cystectomy free survivals, cancer specific and over-all survival were determined. RESULTS: Sixty evaluable patients--median age 63, median follow-up 3.98 years. Forty-two patients (70%) completed BCG-RIVM treatment as planned. BCG termination was necessary in 18 patients (30%). Recurrence occurred in 16 patients (26.7%) at a median follow-up of 24.2 months while progression occurred in five patients (8.3%) at a median follow-up of 33 months. Recurrence-free survival and progression-free survival rates were 73% and 92% respectively. Cystectomy was performed in seven patients (12%) with a cystectomy-free survival of 88%. There were no cancer specific deaths. Two patients died of other causes (3.3%). The overall survival rate was 97%. CONCLUSIONS: Our study is the first to show the clinical efficacy and tolerability of BCG-RIVM strain in the management of high risk NMIBC when given in a schedule of six-weekly induction with monthly maintenance for one year. Our maintenance protocol, achieved equivalent recurrence-free, progression-free, disease specific survival and overall survival to the reported literature and the more intense three-years South West Oncology Group (SWOG) protocol.

Metastatic castration resistant prostate cancer: current strategies of management in the Middle East.

Although most patients with prostate cancer respond to initial androgen-deprivation therapy, progression to castration-resistant prostate cancer (CRPC) is almost inevitable. In 2004, the docetaxel/prednisone regimen was approved for the management of patients with metastatic CRPC, becoming the standard first-line therapy. Recent advances have also led to an unprecedented number of approved new drugs; thus, providing several treatment options for patients with metastatic CRPC. Five new drugs have received US Food and Drug Administration-approval between 2010 and 2012: sipuleucel-T, an immunotherapeutic agent; cabazitaxel, a novel microtubule inhibitor; abiraterone acetate, a new androgen biosynthesis inhibitor; enzalutamide, a novel androgen receptor inhibitor; and denosumab, a bone-targeting agent. Such drugs are either already marketed or about to be marketed in the Middle East. Data supporting the approval of each of these agents are described in this review, as are recent approaches to the treatment of metastatic CRPC.

Stage I seminoma: treatment outcome at King Hussein Cancer Center in Jordan.

BACKGROUND: The aim of this report is to address treatment outcomes of patients with early-stage seminoma in a single institution with special reference to patients with history of surgical violation of the scrotum. METHODS: Seventy four patients with pure seminoma were treated at King Hussein Cancer Center (Amman, Jordan) between 2003 and 2010. All patients underwent orchiectomy. All but 3 patients received adjuvant radiotherapy. Patients who underwent surgical violation of the scrotum prior to referral were managed by further excision or irradiation of the scrotal scar. The follow-up ranged from 1 to 200 months (mean, 33 months). RESULTS: At the time of follow-up; all but one patient remain alive. The 3-year relapse-free survival for the entire cohort was 95.9%. Three patients developed relapse, all of whom received adjuvant irradiation following inguinal orchiectomy and initially harbored tumors larger than 4 cm upon pathological examination. Median time to relapse was 14 months (range, 8-25 months). None were associated with elevated tumor markers prior to detection of relapse. All but one patient were successfully salvaged by chemotherapy. CONCLUSIONS: Our results confirm the excellent prognosis of patients with early-stage seminoma treated by orchiectomy and adjuvant radiotherapy in a developing country. Although all patients who developed relapse demonstrated adverse pathological findings upon initial assessment, no consistent predictor of relapse was found. Scrotal scar re-excision or irradiation in patients with prior history of surgical violation of the scrotum are effective measures in preventing local failure.

Multiple primary malignancies: analysis of 23 patients with at least three tumors.

BACKGROUND: There is scarcity of reports addressing patients with three or more malignancies. The aim of this study is to present a detailed analysis of patients presenting with at least three primary malignant tumors. PATIENTS AND METHODS: Records of cancer patients presenting to King Hussein Cancer Center (Amman, Jordan) between June 2006 and March 2011 were retrospectively reviewed. Patients harboring multiple primary tumors were included for detailed analysis. Data relating to epidemiological features, pathological characteristics, and disease outcomes were extracted. RESULTS: Out of 14,040 cases, 319 patients (2.3%) harbored two or more while 23 patients (0.16%) harbored three or more primary malignant tumors. This study included 17 males and six females between 4 and 78 years of age (median, 52 years) at the time of diagnosis of the first malignancy. The most prevalent tumor was colorectal adenocarcinoma found in nine, followed by lymphoma in seven, and prostate adenocarcinoma in six patients. The most common tumor combinations were colorectum-non-melanoma skin, colorectum-kidney, and non-melanoma skin-kidney all found in four patients, respectively. At a median follow-up of 96 months from the time of diagnosis of the first primary (range, 2-337 months) and 8 months from the time of diagnosis of the last primary (range, 1-48 months), 13 were alive with no evidence of disease, six were alive with residual disease, three were dead due to disease, and one patient was alive with unknown disease status. CONCLUSIONS: The possibility of multiple primary malignancies should always be considered during the treatment and follow-up of cancer patients. This case series could prove helpful to clinicians faced with similar, however, exceedingly rare scenarios. Due to the realistic potential for long-term survival, we recommend aggressive treatment of these patients.

Bladder preservation by concurrent chemoradiation for muscle-invasive bladder cancer: Applicability in low-income countries.

BACKGROUND: Radical cystectomy is the standard treatment for patients with muscle-invasive urinary bladder cancer; however, is associated with major treatment - related morbidity. Furthermore, a significant proportion of patients are deemed unsuitable for surgery due to inoperability, advanced age, and/or comorbid conditions. As such, several groups have explored effectiveness of less radical therapeutic strategies that aim at bladder preservation. Nonetheless, there is scarcity of reports assessing the applicability of urinary bladder-sparing outside developed countries. AIM: Determine the achievable outcomes for patients with muscle-invasive urinary bladder cancer treated via bladder-sparing techniques in a low income country. MATERIALS AND METHODS: Fourteen consecutive patients with a diagnosis of muscle-invasive urinary bladder cancer (clinical stage; T2-3N0M0) were treated via a bladder-sparing approach at King Hussein Cancer Center (Amman, Jordan) between 2005 and 2009. Records were electronically retrieved and retrospectively analyzed and included 11 males and 3 females from 41 to 74 years of age (median age, 61). Initial therapy consisted of trans-urethral resection of bladder tumor (TURBT) followed by induction chemotherapy then irradiation (4500cGy) with concurrent platinum-based chemotherapy. Urological evaluation directed additional therapy in a proportion of patients with irradiation (up to 6400 cGy) in patients who achieved CR. RESULTS: Eleven patients were evaluable for pathological response at time of re-staging; of whom 8 (73%) achieved CR and 3 (27%) achieved partial response (PR). In all but one patient; combined-modality treatment was well tolerated. After a median follow-up of 18.5 months (range, 3-48 months); 5 of 8 (62.5%) patients with CR were alive. CONCLUSIONS: Bladder-sparing strategies via concurrent chemoradiation for muscle-invasive bladder cancer results in an acceptable rate of complete pathological response with adequate short-term outcomes. This approach appears applicable in low-income countries.

Infecciones del tracto urinario en varones adultos y adolescentes en una comunidad en vías de desarrollo: patrones, bacteriologia y factores predisponentes genito-urinarios / Urinary tract infections in adult and adolescent males of a developing community: pattern, bacteriology and genito-urinary predisposing factors

OBJETIVOS: Analizar 95 casos consecutivos de infección del tracto urinario (ITU) en varones adultos y adolescentes, para determinar el patrón, la bacteriología y los factores predisponentes. MÉTODOS: 95 pacientes consecutivos fueron incluidos durante un periodo de 12 meses. Los pacientes eran varones adultos o adolescentes con ITU. La edad oscilaba entre 13-100 años (mediana 55, media 53,3 años).RESULTADOS: Las ITU nosocomiales y adquiridas en la comunidad aparecieron en el 40 por ciento y 60 por ciento de los pacientes respectivamente. Se aisló E. Coli en el 66,7 por ciento de las infecciones extrahospitalarias, lo que está muy por debajo del 80-90 por ciento referido en la literatura. CONCLUSIONES: Enterococo y Enterobacter Spp.Parecen ser patógenos emergentes como fuente importante de ITU hospitalarias y extrahospitalarias en varones. La causa de la infección en más del 50 por ciento de los casos fue la obstrucción del tracto urinario inferior, mientras que los tumores malignos del tracto genitourinario son la causa en casi el 20 por ciento de los pacientes. Se discuten las implicaciones de estos hallazgos (AU)

Urinary tract infections in adult and adolescent males of a developing community: pattern, bacteriology and genito-urinary predisposing factors.

OBJECTIVES: Analysis of 95 consecutive adult and adolescent males with urinary tract infections to determine the pattern, bacteriology and the predisposing causes. METHODS: The period was 12 months, and the number of patients was 95 consecutive cases. They were adult and adolescent males with urinary tract infection. Their age ranged from 13-100 years, (median 55, mean 53.3 years). RESULTS: Hospital and community acquired urinary tract infections occurred in 40% and 60% of patients respectively. E. coli was isolated from 66.7% of community acquired infections, which was well below the reported literature of 80-90%. CONCLUSIONS: Enterococci and Enterobacter spp. Appear to be emerging as important hospital and community acquired urinary tract pathogens in males. Bladder outflow obstruction accounted for over 50% of all genito urinary causes of urinary tract infections, while genitourinary malignancy occurred in nearly 20% of patients. The implications of these findings are discussed.